CQC report highlights impact of mental health bed pressures on patient care

A shortage of available beds to meet demand for admissions at a north London mental health trust is damaging patient care, CQC reports show.

A set of reports from a wide-ranging inspection of Camden and Islington NHS Foundation Trust’s community and inpatient services highlighted several areas of good practice but identified a series of concerns stemming from problems accessing beds for acutely unwell patients.

The impact on patients and staff

The CQC found that bed occupancy at the trust averaged 96.4% between October and December last year, compared to the an average of 85.9% across England. Staff and patients told CQC inspectors that the pressures on beds had led to:

• Home treatment teams caring for people in need of hospital care. Staff in crisis resolution teams said that problems securing beds meant there were occasions when they were left giving home treatment to people they felt needed hospital care. However, they said that a bed would normally be found if they ‘escalated’ their request. Staff at crisis houses, services commissioned as an alternative to hospital admissions, also said there were times when they cared for people that needed admission to an acute award;
• Patients being shifted between wards to free-up beds. In an effort to free-up beds on assessment wards and maintain gender ratios on wards, the trust had moved people between wards multiple times. Some people were transferred to wards where they didn’t know and were not known by the care team. In the last financial year, over 100 people had been transferred between wards overnight, the CQC found. Since April, the number of overnight transfers had been cut to eight. The trust said it has since introduced a policy of no overnight transfers;
• Patients on leave having no bed to return to. The CQC were told that pressures on beds “are so great” that patients who go on short-term leave may not have a bed available when they need to return as the bed is used by another person. On one ward a serious incident occurred while staff were busy trying to locate beds for two people who had returned from leave but their beds were full;
• People being ‘discharged too quickly’. People using the service told inspectors they were concerned about how quickly they were discharged from beds. One said “they discharge you as soon as you can do up your shoes”.  The CQC found that the average length of stay had decreased over the last year;
• Patients being sent to out-of-trust beds. Between April 2013 and February 2014 the trust placed 76 patients in beds outwith Camden and Islington due to its own bed capacity being full. Most of these were within the greater London area, the CQC found;
• Most admissions being under the Mental Health Act. Staff said that most people accessing acute inpatient beds were now detained under the Mental Health Act, rather than informal admissions.

The CQC reports echo many of the findings of a series of investigations by Community Care and BBC News into the impact of bed pressures and funding cuts at mental health trusts across the country.

Sue, who has used mental health services in Camden and Islington for a number of years, told Community Care that the standard of crisis care she receives has deteriorated in recent years.

“Some years ago one of the crisis houses worked particularly well for me. But after there were massive cuts in 2011 or 2012 things went downhill. Now the crisis houses can all have waiting lists for you to even get an assessment. All of them can refuse people and do,” she said.

“So you end up with situations where you’ve got one team trying to keep you out of hospital and restricting your options on the one hand but at the same time the crisis houses telling you you need to be in hospital. So you get caught between these arguments about who will assess you and you know that even if you need hospital you won’t get a choice of voluntary admission. It’s appalling.”

How the trust is responding

In response to the CQC report, Wendy Wallace, chief executive of Camden and Islington NHS Foundation Trust, told Community Care that the trust’s acute inpatient services were experiencing a “very pressured” period. The trust had purchased overspill beds at neighbouring NHS trusts in London to minimise the distances patients had to travel if local beds were full, she said.

“We know that in the last year, we’ve mostly only sent people within London. But it is very difficult because there have been days this summer when there have been no beds in London or the private sector as we are not the only trust experiencing these pressures,” she said.

In response to the bed pressures, the trust opened a fourth crisis house in January and has set up a specialist discharge team. The trust has also reduced the number of times patients are transferred between wards for non-clinical reasons, Wallace said. Any transfers that do happen are always to wards on the same site and an electronic system is now in place to ensure continuity of care, she added.

Wallace said the trust is also working to pin down the factors driving the pressure on beds. Early analysis had identified a range of issues including a “substantial increase” in patients presenting at the trust who have had no previous contact with services and delays getting housing placements for certain groups of patients who are ready to leave hospital, she said.

Data obtained by Community Care under the Freedom of Information Act last year showed that the trust had closed over 100 mental health beds since April 2011. Wallace said that the move had been consulted on and was “right at the time” as the majority of the beds earmarked for closure had been vacant. A national review of the pressures on the system was needed, she added.

“In terms of parity of esteem, if this was acute hospital beds [for physical health emergencies] it would be on the secretary of state for health’s agenda every day,” she said.

“We need some serious work done on what is actually happening in the system. Until we understand it, we can’t tackle it fully. It may be that we need more beds. It may be that we need more crisis systems. It may be that we need more rehabilitation beds. We have to get it right to make sure that the investment works. This isn’t just individual trusts experiencing this.”