Patients at risk as ‘unsafe’ mental health services reach crisis point

Community Care investigation prompts minister to pledge to end "institutional bias against mental health" in NHS

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.

Our investigation found that professionals are routinely struggling to get emergency hospital care for patients in crisis as the NHS has shut more than 1,700 beds in two years. Adult psychiatric wards are running occupancy levels of more than 100%, meaning some patients are being sent to private hospitals miles from home or admitted to NHS hospitals without a bed.

One patient took her own life two days after professionals tried to admit her to an NHS unit only to be told there were no beds available.

The investigation also found:

    • A whistleblower alerted social care regulator the Care Quality Commission after an NHS trust admitted patients to hospital without beds being available as no beds could be found in the public or private sectors.
    • The NHS continues to spend millions of pounds sending severely ill patients to private hospitals, often hundreds of miles from home.
    • Children and young people are being admitted to adult psychiatric wards due to nationwide pressures on specialist children’s beds.
    • Patients admitted to wards are “increasingly seriously ill” placing an extra strain on ward staff.
    • Pressures to free-up beds are leading to patients being discharged too early, social workers warn. At one trust bed pressures meant one patient was admitted eight times in 12 months.
    • Patients have warned NHS executives that acute services “are in crisis and cannot cope with demand”.

In response, care and support minister Norman Lamb said he was determined to end the “institutional bias in the NHS against mental health”. The minister admitted current levels of access to care “are unacceptable” and said “beds must be available if patients need them”.

The investigation is based on freedom of information requests to NHS mental health trusts and analysis of trust board papers published this year.

Demand outstrips supply

This analysis found that demand for crisis services is outstripping the NHS’s shrinking bed supply. Despite Mental Health Act admissions hitting a record level of 48,000 in 2011/12 (2012/13 figures are due later this month), data obtained from freedom of information requests to 48 NHS Trusts showed at least 1,700 mental health beds have been closed since April 2011.

Three-quarters of bed cuts (1,291 closures) were made on admission wards and psychiatric intensive care units for acutely unwell adults and older people.

The NHS’s remaining inpatient units are overstretched. Ward occupancy data obtained from half of England’s mental health trusts found adult admission wards averaged an occupancy level of 101% on 1 August this year.

Although the Royal College of Psychiatrists recommends occupancy levels of 85%, individual wards were running at up to 138%. Wards are usually managing the excess by filling beds temporarily freed-up when patients are sent on short-term leave, a situation one social worker warned is risky as patients who relapse “are not able to return to the ward if they need to”.

One trust’s complaint log revealed an incident where a patient “on weekend leave was refused re-entry back into the ward on the Saturday even though he was in crisis. The ward informed [the patient’s] carer that his bed had been allocated to another patient and that there was no room for him.”

In other cases patients have been admitted to hospital without a bed being available. A whistleblower contacted the Care Quality Commission after South West Yorkshire NHS Partnership Trust admitted patients without a bed 12 times in five months because no beds could be found in the NHS or private sector.

Patients waited in seclusion rooms until beds became available, an issue also raised at a north London hospital earlier this year. The CQC told South West Yorkshire Partnership Trust the practice was “unacceptable and must not continue”. The trust said “at no point was any service users’ safety compromised”.

Lucy Bowden ended up in the back of a police van due to a lack of beds after voluntarily seeking help. The 33 year old, who has a history of self-harming, was left wandering around the grounds of her local accident and emergency hospital after being told there were no psychiatric beds available.

Eventually the police were called, who had to use their powers under the Mental Health Act to force her local psychiatric hospital to provide her with care. “They couldn’t find anywhere so they were saying I’d have to go in to police custody, in a police station which would mean I’d have to go into a cell. Eventually they found a bed and I had to go into the back of a police van, in the cage in the back. It was horrible,” she said.

NHS spends millions on private care

The bed shortage also means the NHS is spending millions of pounds sending growing numbers of patients to private hospitals, often miles from home, a situation first raised by Community Care earlier this year as social workers warned it was isolating patients from their support networks.

Since our report, Manchester Health and Social Care Trust has spent £1.75m on out-of-area private beds in four months. The trust said plans for additional NHS bed capacity would be in place by the end of the year.

Social care leaders and psychiatrists have warned that the system is “unsafe” and needs urgent reform.

Faye Wilson, chair of the British Association of Social Woker’s (BASW’s) mental health forum, said failure to address the situation risked a “crisis on the level of Mid Staffs”, referring to the Staffordshire hospital care scandal judged to be one of the worst in the NHS’s history.

She added: “If we were treating cancer patients like this there would be a national outcry. Yet here we have a national problem in mental health and it feels like no-one is listening.”

Steve Chamberlain, chair of The College of Social Work’s network for approved mental health professionals (AMHPs) – the group of mostly, but not exclusively, social workers who carry out Mental Health Act assessments, said: “There is no doubt that patient care is compromised by the lack of resources for acutely ill individuals.

“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.”

Martin Baggaley, medical director at South London and Maudsley NHS Foundation Trust, said: “We are in a real crisis at the moment. Currently the system is inefficient and unsafe. We’re certainly feeling it on the frontline, it’s very pressured, and we spend a lot of our time struggling to find beds, sending people across the country, which is really not what I want to do.”

Many bed closures are justified by the NHS by promises that savings will be reinvested in community services. But Dinesh Bhugra, a psychiatrist who chairs the Mental Health Foundation, said: “Around the country there is a lot of pressure on community teams and lots of staff are going off sick. I cannot see any logical explanation for closing beds.”

Care and support minister Norman Lamb said: “More people are being treated in the right settings for them, including fewer people needing to go into hospitals. It is essential that people get the treatment they need early and in the community but beds must be available if patients need them.”

The minister said the government is working with NHS England to assess how long people wait for treatment with a view to introducing national standards for mental health. The CQC’s impending appointment of a deputy chief inspector of hospitals with mental health expertise would help “root out poor care”, Lamb added.

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12 Responses to Patients at risk as ‘unsafe’ mental health services reach crisis point

  1. John Sidney Gilmore October 16, 2013 at 7:16 am #

    Nothing new here at all.

    I’m a mental health nurse, who trained in northern England in the mid-80s: I remember bed occupancy rates of 110% then, with leave beds being used, beds being made up in a gym area and the like;

    When I worked on acute and secure wards in south west England in the late ’90s, it was quite usual for there to be no locally available beds, patients going anywhere as far a Bangor for a bed, or, in one instance at least, a guy being nursed in a police cell for 3 days before a bed became available;

    As for CAMHS (the area I worked in or around 25 years), we have lost beds, which were never numerous. I know of many instances of young people admitted to adult wards or paediatric wards with support from CAMHS nursing staff, I can recall, when I worked on Teesside, spending half a day on the phone trying to find a bed for an acutely psychotic teenager, only to find that the nearest one was a private one in Northampton…

    Now, these are just the experiences and memories of ONE nurse…

    All of these things are well known to anyone who has worked in management of MH services over the last 30 years, and anyone who says they didn’t know is…let’s not beat around the bush…lying…and that includes anyone up to the DoH and the politicians involved.

    These things have been well known and complained about by clinical staff and patient groups, but have been routinely ignored.

    Commissioning is often a joke, with no-one involved who has any MH knowledge or experience. This has been especially true, in my experience, in CAMHS, despite there being good, written advice and recommendations on commissioning available in documents such as “Together We Stand” (I can rcall asking a couple of our local commissioners for CAMHS if they had read “Together…”, they hadn’t even heard of it!

    This is a well known scandal and those responsible have been and are at the top of services: senior managers who ignore their staff and patients; commissioners who have no idea what they are commissioning; and, most especially, the politicians who control the purse strings and the systems within which we have to operate.

  2. Don Philpotts October 16, 2013 at 10:02 am #

    Economics have made this decision; Care in the Community is systemically flawed. How many Homicides and Suicides will it take; how many victims families must there be before this is addressed. Better treatments more research on causes and treatments. In the meantime more bed/safe places might avert some of the tragic consequences that are revealed everyday – and may also alleviate the chaos placed on carers and loved oned trying to look after someone when the Mental Health Services either do not care or do not have the resources to cope. The families can’t clock off at 5pm.

    • John Sidney Gilmore October 16, 2013 at 11:07 am #

      It’s more a case of “do not have the resources to cope”.

      When I worked in one particular CAMHS community service, our staffing levels were below those recommended in the NSF, posts were frozen whenever anyone left (mine has disappeared following my recent retirement), and yet various managers would not allow us to raise issues of staffing or resources generally in management team meetings, while in the next breath “asking” us to meet ever more ridiculous targets with fewer staff…

    • ladybird (@lizzydripping) October 16, 2013 at 6:21 pm #

      i get your distress Don, but even though the day may finish at 5pm i and many others are working late to try and meet the needs of families and services users, and its not that we dont care its the resource issue………..unfortunately the people who make decisions about services often have no experience of work at the frontline. the NHS is managed as a business model and people become numbers…….

      there is long term sickness where staff are just becoming burnt out with the stress of it all.

  3. John Sidney Gilmore October 16, 2013 at 12:02 pm #

    And before anyone asks “What did you do about it?”, let me tell you what I tried to do:

    As a student raised concern via the school of nursing – nada;

    As a staff nurse raised concerns with ward management, next level of managemen – zilcht;

    As a ward manager raised concerns with next 2 levels of management. Then went over their heads, which got me threatened with a variety of things – naff all;

    In community posts, where my job was a times team co-ordinator, raised concerns with next 3 layers of management – bugger all;

    Wrote an article for the Nursing Times about staffing in MH services – didn’t want to know;

    Contributed to 2 external reviews of my service, raising concerns about staffing and the lack of attention management pay to our concerns – both reports have been “disappeared”…

    One struggles to know how else one can raise concerns when no-one is listening.

  4. ladybird (@lizzydripping) October 16, 2013 at 6:23 pm #

    yes we are just invisible drones…….

  5. Charlotte October 16, 2013 at 7:14 pm #

    We’ve had some dreadful situations recently caused by lack of bed availability. An autistic patient living in our POS suite for weeks. Patients being sent home on leave and not having a bed to come back to. AMHPs arriving at hospital with a patient in the belief a bed is available only to be told the last bed has just been given to someone else. Patients being assessed by out of hours service being stuck in the police custody suite or the POS for hours while a bed is sought. As an AMHP this particular situation is very worrying as an application for detention cannot be written without a bed first being identified.Keeping someone for hours after a Mental Health Act assessment has been completed without a clear legal basis while a bed is being looked for adds extra pressure to an already stressful situation, particularly during community based assessments where the AMHP is often the last person left with a patient. I can only imagine what it must feel like for the poor person on the receiving end of all this.

    I’m also aware of discussion elsewhere in the country of AMHPs not even undertaking assessments under the MHA until they know a bed is available for exactly this reason – surely this is a disaster waiting to happen. I can imagine the Sun headlines already.

  6. Duncan Double October 16, 2013 at 7:53 pm #

    See blog post about reinvigorating community psychiatry

  7. J Smith October 16, 2013 at 9:36 pm #

    The culture at present seems to be one of targets targets targets, managers are under so much pressure to reach targets they’ve stopped thinking about people as humans (patients and staff). Anyone above team manager level right up chief executive level don’t want to know about the lived experience of patients/service users, carers or staff on the front line, I truly believe they are so far removed from what is going on despite being told repeatedly that they just stop listening to frontline staff, families and service users and start believing that everyone is moaning and not being positive. Experienced staff are being burnt out, newly qualified staff can’t or won’t stick around once they find out what it’s really like on the front line and this means patients and carers are left without the support they need. Private hospitals are getting paid fortunes but are not able to deliver when it comes to aftercare, discharge planning etc and why should they when they can make so much money without having to bother with it all. If the money being spent on paying for NHS patients to be in private hospitals was spent on NHS mental health services millions would be ploughed back into essential services. Trust boards seem to be made up of people who want to safeguard their own jobs, much like the government. It is as if they are playing at it, making their mark and then moving on with no regard for the devastation left behind

    • John Sidney Gilmore October 17, 2013 at 8:18 am #

      No-one asked those in management positions to do those jobs: this is a self-selecting group of people, who think they could/should do those jobs, selected by a very like-minded group, which keeps a prevailing culture going. No-one who challenges that culture is allowed in.

      At least one trust I worked for had a chief exec whose mantra was “Bring me solutions, not problems!” Result was the lower levels of management just hid any difficulties, resulting in near paralysis at the sharp end as no-one would take any remotely difficult decisions.

      As I said, these people are culpable in the extreme.

  8. Sophie October 16, 2013 at 10:33 pm #

    Maybe legal highs need to be focused on as theae are proving to be a big problem. A large amount of patients mental health is being affected by these illicits unnecessarily prolonging treatment and occupying beds.

  9. alea October 18, 2013 at 11:48 pm #

    am one of those patients one of those people now cant get any help there is nowwhere and know its the end of the so scared violent death planted thoughts. police here 3 times after s136 x2 in cells last week.they told no MHA as no beds this area london.nowhere left. told wait no meds on choice