Mental health crisis services in England are “unsafe” and delivering substandard care to acutely unwell adults and children, an investigation by Community Care and BBC News has revealed.
Here are 10 ways the crisis is hitting patient care.
1. Patient death
In north Essex 33-year-old Amanda Peck took her own life two days after professionals had tried to admit her to an acute hospital ward only to be told there were no beds available. A subsequent investigation found that one bed had been available but was marked as “in use” in case a patient needed to be readmitted.
No attempt to find an external bed was made, a situation North Essex Partnership NHS Trust said was in breach of trust protocol.
What the NHS Trust said: “The on call person phoned the wards and found all beds had patients attached to them. At least one bed was empty as some patients were on home leave (a preparation for discharge) but the bed is still marked ‘in use’ in case the person needs to return quickly.
“We have now changed this system so that any bed that is empty is made ‘available’ for other emergency admissions (including those beds where the patient is on leave). If there are no beds available in North Essex we expect arrangements to be made for one out of area. We have a funding agreement with the commissioners that allows this to happen.
“An admission was felt to be necessary; the bed was not found and a care plan made on that basis. It is very difficult to say if her death could have been avoided with an admission at that time. Nevertheless we are sorry for the outcome and understand completely why the family feel let down.”
2. Patients admitted to hospital without a bed
A whistleblower alerted the Care Quality Commission after patients were admitted to hospital without a bed 12 times in five months at South West Yorkshire NHS Partnership Trust due to no NHS or private beds being available. The Mental Health Act includes a provision for patients to be admitted to hospital “in cases of special urgency”.
What the NHS Trust said: “Admission has only been progressed where safety is paramount and after all other NHS and independent bed options have been explored. At no point was any service user’s safety compromised.”
“The service users affected were a mix of informal patients admitted voluntarily and those admitted formally under part 2 of the Mental Health Act. They were cared for by using a ward low stimulation room and other ward accommodation as a temporary bedroom.”
What the CQC said: “We told the trust that this practice was unacceptable and must not continue. The trust accept that admitting patients without sufficient bed space is not in line with best practice and has outlined the steps they are undertaking to prevent future occurrences. We are continuing to monitor the situation carefully and have a range of enforcement powers at our disposal should this be necessary.”
3. Patients sent to private hospitals costing the NHS millions
Manchester Health and Social Care Trust has already spent £1.75m in four months this year sending patients to out-of-area private hospitals due to a shortage of NHS beds, a nationwide issue raised by Community Care earlier this year. Social workers warn out-of-area placements isolate patients from support networks but NHS trusts say they are necessary during spikes in demand for beds.
What the NHS trust said: “It is recognised that Manchester has, for several years, been under-resourced in relation to acute mental health bed provision. The trust and commissioners are working on proposals to put in place additional external NHS capacity in order to increase the adult acute bed provision in the city. This is expected to be fully operational by the end of December 2013.”
4. The clinical risks of high occupancy
An official report from one NHS mental health trust listed the following clinical risks associated with high ward occupancy levels:
- Quality of care may be affected as the demand for resources increases
- Sleep outs are taking place. This affects the quality of care, interrupts therapeutic relationships and is a cause of dissatisfaction to patients and carers
- Patients who need intensive care have been occupying acute beds
- There is an increased risk of incidents
- Service user and carer satisfaction is affected
- Being able to accommodate gender separation is more challenging
- Increased bed occupancy is linked to increased clinical risk. This affects staff morale, performance and sickness. Sickness rates
- have been coming down in recent times, this could change.
5. Patients being readmitted shortly after discharge
An analysis by Avon and Wiltshire Partnership NHS Trust found bed pressures had led to around 14% of patients having repeat admissions, with one patient having had eight admissions in a 12-month period.
What the NHS trust said: “The August board report highlighted the problems we were facing and the way bed pressures were impacting on the quality of our care. Since then we have worked with our partners to reduce the pressure on acute mental health beds. A new bed management system is being set up to ensure that we use our beds most effectively, with the aim of people being admitted to the bed most local to them.
“We are also reviewing services to ensure that only people who really need to be in hospital are admitted, and then only for the therapeutically shortest time. We are working with social care colleagues to make sure people are discharged in a timely way so that when AMHPs assess someone as needing a bed, there is one available for them.”
6. Patients forced to ‘sleep over’ on older adult wards
Twenty-nine patients were treated on acute wards during the day but had to ‘sleep out’ at other units, including older people’s services on a different site, as bed occupancy at Oxleas NHS Trust hit an average level of 125% earlier this year.
What the NHS trust said: “There was definitely a peak in demand in June and July this year, however we have made good progress in managing and reducing this since then. We have increased investment in our home treatment teams who have been strengthened and are more able to avoid unnecessary admissions and facilitate early discharge where it is appropriate and safe.”
7. Crisis services ‘can’t cope with demand’, warn patients
At a July board meeting patients told executives at Kent and Medway Partnership that the NHS Trust’s acute services “were in crisis and could not cope with demand”. One patient said she had personally experienced “a very poor response” from services. She said it was NHS and public service staff who asked her to raise the concerns.
Data obtained by Community Care showed that the trust had an average occupancy of 107% on its acute wards on 1 August. Medway council has recently referred NHS plans to close beds in Medway to the health secretary, arguing that they are not in the best interest of patients. The trust argues overall bed numbers will increase under the plans.
What the NHS trust said: “We are working to deliver revised bed numbers as agreed with commissioners as per bed sensitivity analysis. We have also invested in crisis resolution and home treatment team and expanded the psychiatric intensive care outreach service to cover the whole of Kent and Medway. We recognise inpatient beds do not provide the total answer and that alternatives need to be developed.”
Alternatives under consideration include crisis houses but these plans would depend on funding from commissioners, the trust said.
8. Children admitted to adult units
Six patients under-18 were admitted to adult wards at Nottinghamshire Healthcare NHS Trust between April and September due to nationwide pressures on specialist children’s beds. The situation is not isolated to Nottinghamshire, with concerns raised with health secretary Jeremy Hunt in recent months.
What the NHS trust said: “We have special measures in place to safeguard the young person involved and work closely with them and their family to ensure they are well cared for. We have recently reduced this risk on our risk register as this issue has become less acute over the last couple of months.
“We continue to work with commissioners from the area team of NHS England to monitor this situation and a strategy group has been established with them on which the trust has a representative. There isn’t a short term fix for this issue, which is a national problem.”
9. Emergency admissions are being delayed up to three weeks
Mentally ill people assessed by professionals as needing urgent hospital care are having to wait up to three weeks for admission due to the bed shortage, a survey by The College of Social Work found earlier this year.
Steve Chamberlain, chair of The College of Social Work’s AMHP leads network, said Community Care’s investigation backed up the survey findings.
“There is no doubt that patient care is compromised by the lack of resources for acutely ill individuals, and this fully reflects the results of the survey of AMHPs carried out earlier this year, with significant delays to admission, admission to beds far from people’s home areas and premature discharges which lead to readmission”
“AMHPs (and other mental health professionals) are finding it increasingly difficult to do their jobs, as they are working in a system where the resources needed to keep individuals safe in crisis are just not there. However skilled and committed the professionals, the likelihood of further tragic incidents will just increase.”
10. Frontline staff placed under “unacceptably high” stress levels
The most recent national AMHP survey found that over a fifth of professionals who trained as AMHPs wanted to quit the role, with bed pressures cited as a major stress factor.
Andy McNicoll is Community Care’s community editor