Mental health patients failed by ‘unsafe’ crisis care system, CQC finds

England’s mental health crisis care system is ‘unsafe’, with patients reporting problems with care that would be unthinkable in physical health emergencies, a review by the Care Quality Commission (CQC) has found.

The care watchdog reviewed the way health and care services responded to mental health emergencies when people came into contact with specialist services, A&E departments or the police. The CQC drew on 1,800 survey responses from mental health patients, their carers and local organisations. National data and findings from CQC inspections of 12 local care pathways also fed into the review.

The regulator’s wide-ranging report identified some examples of ‘good practice’ but warned that the quality and availability of care was too inconsistent. The review also highlighted a series of common failings in crisis care that the CQC said should serve as a ‘wake up call’ for NHS commissioners, health providers and local authorities.

The CQC said such feedback would be ‘unthinkable’ in physical health emergencies

Concerns over care

A lack of bed availability at mental health units was a key concern raised in the CQC’s call for evidence. This meant patients were being sent to out-of-area hospitals due to local bed shortages. Evidence also indicated that people were turning to A&E because they felt unable to access help from community mental health services, particularly out-of-hours.

Problems were also identified with crisis resolution home treatment teams. The services are supposed to offer intensive home treatment as an alternative to hospital admission. However, the review found that some crisis teams struggled to offer an adequate home treatment function, with a lack of frequent visits, inconsistency of staff and a lack of support sources of “major frustration” for people using services.

Findings from a survey of crisis teams, included as part of the review, found that over half (56%) failed to meet any of the criteria deemed to indicate effective alternatives to hospital admission. A separate analysis also raised “serious questions” about whether crisis teams had processes in place to manage people at risk of suicide.

The review highlighted a welcome reduction in the use of police cells as a place of safety for people detained under section 136. But patients still faced delays in accessing health-based ‘place of safety’ units due to them being full or short staffed.

Once in a place of safety most people were assessed within three hours. However, some assessments were delayed due to a shortage of Approved Mental Health Professionals or doctors. Data from a Home Office pilot project included as part of the review also suggested that police vehicles were routinely used to transport people in crisis to a place of safety, most commonly due to problems with ambulance availability.

Staff attitudes

The review also asked people with experience of services about the attitudes of staff towards them.

Just over a third of patients (37%) who had ended up in A&E felt staff took their concerns seriously. Community mental health teams (44%) and crisis teams (48%) fared little better. Higher ratings were seen when patients were asked about police (54%) and GPs (64%). The highest satisfaction was with voluntary services, where 86% of people felt their concerns were taken seriously.

‘A system that is unsafe and unfair’

Overall only 14% of people responding to the survey felt they got the crisis care they needed. Almost half of respondents were not confident they would receive a timely or helpful response if they had a future crisis.

“A health and care system where such a low proportion of people think they get the urgent help they need is one that is unsafe and inherently unfair,” the CQC report said.

It added: “This kind of feedback would be unthinkable for physical health emergencies and it should also be seen as unacceptable for people with mental health emergencies. While we recognise that it may not be possible to fully resolve every crisis event, these results suggest that local organisations are not consistently meeting the needs of people in crisis.”

Much in the CQC review echoes the findings of a series of analyses carried out Community Care and BBC News over the past 18 months.

Our research revealed that mental health patients were being sent up to 300 miles from home for beds. We also identified a series of deaths linked to problems accessing beds for patients in need. An investigation into funding found that NHS trusts had seen their budgets for mental health drop 8% in real terms over the course of the last parliament. Investment in key community services to keep people out of hospital fell by 5%, while referrals rose around 20%.

‘Wake up call’

Dr Paul Lelliott, the CQC’s deputy chief inspector of hospitals, said that the regulator’s findings showed local organisations must “act decisively” and use the government’s crisis care concordat as a vehicle to make much needed improvements to care.

The concordat requires health, social care and criminal justice organisations in each area to outline an action plan for delivering high quality round-the-clock crisis care locally. It was introduced by former care minister Norman Lamb as part of the coalition government’s commitment to delivering ‘parity of esteem’ between mental and physical healthcare.

Responding to the CQC findings, Alistair Burt, Lamb’s successor as care minister, said the Conservative government was committed to addressing problems with the system.

“Improving mental health care is my priority. I am clear that there is so much more to achieve and we all need to work together to achieve it,” he said.

“The CQC will now inspect crisis care arrangements in every service and I have asked them to continue to help stamp out poor care and help us to make sure that people with physical and mental health conditions are treated with equal importance.”

‘National response needed’

Faye Wilson, chair of the British Association of Social Workers’ mental health forum, said the report provided an honest assessment of the scale of problems facing services.

“We have a fragmented system in place and there are major issues around beds and the functioning of crisis teams and community teams. In a lot of places crisis teams are not able to provide effective home treatment and the CQC survey findings indicate that the culture in some teams is defensive rather than defensible,” she said.

“We have known about a lot of these issue for some time but the CQC has given an important national overview. The question now is what role central government will play in providing a national response. The crisis care concordat has led to improvement in some local areas but if it doesn’t have teeth it won’t be effective in addressing system-wide problems.

“The concordat relies on areas having strong local partnerships and that won’t be the case in every area. We know how weak some clinical commissioning groups are on mental health. We also know there is not enough funding in the system nationally. Today’s findings need national action as well as local changes.”

Paul Farmer, chief executive of mental health charity Mind, said: “This report is a clear call to action. Mental health services are the victim of years of neglect and funding cuts over the last few years have taken their toll, at a time of rising demand. National and local commissioners must now make mental health a priority and invest in the future of our mental health services.”