Mental health system failings breaching patient rights and damaging care, finds CQC

A series of failings in the way mental health services are being commissioned and run is damaging the care of patients detained under the Mental Health Act and undermining their rights, a report by the Care Quality Commission has found.

The CQC said improvements were “urgently needed” in NHS and social care services after its Monitoring the Mental Health Act 2012/13 report found evidence of substandard inpatient, crisis and out-of-hours care. NHS commissioners in many areas had also failed to meet their statutory duty under the Act to plan for cases of mental health patients requiring hospital admission as a matter of “special urgency”, the report said.

There were 50,408 Mental Health Act detentions in 2012/13, the highest number on record. The number of people detained under the Act has risen 12% in the past five years, the CQC said.

A number of problems identified by CQC stemmed from a shortage of available mental health beds, or appropriate community alternatives, for patients in crisis. A recent investigation by Community Care and BBC News found that over 1,700 mental health beds had been closed since April 2011, with bed pressures harming patients and staff.

Crisis care and commissioning issues

Approved Mental Health Professionals (AMHPs) – the group of mostly, but not exclusively, social workers that carry out Mental Health Act assessments – told the CQC they had experienced “extreme difficulty” accessing beds. AMHPs also raised concerns that resource shortages had limited their ability to safeguard patient rights.

The CQC found that problems with crisis care meant that:

• Patients, including an 11-year-old child, were detained to police cells due to NHS ‘place of safety’ units being unstaffed or having no available beds. “Some have lain empty while a patient has been taken to police custody,” the report found.
• Patients had received “overly restrictive” care after a lack of available beds led to them being admitted to wards geared up to deliver more intensive care than clinically necessary. “Admitting a patient to a more intensive or secure regime than is clinically justifiable is likely to breach the {Mental Health Act] Code of Practice principle of always using the least restrictive alternative to provide care,” the report said.

• AMHPs often faced delays of four to five hours in getting a bed. One patient was assessed three times in 24 hours because AMHPs were told that beds they had eventually managed to secure had been allocated to other patients by the time an ambulance arrived.
• Strong anecdotal evidence suggested bed pressures are “distorting the thresholds” for detention. “For example, we have heard of occasions where patients have been detained not because they object to hospital admission per se, but because they object to admission to the available hospital bed which is out of their home area,” the report found.
• Staff were put under pressure to discharge patients to free-up beds, a situation that risked patients being put on Community Treatment Orders (CTOs) as a “safety net” if necessary. CTOs allow professionals to impose strict conditions on supervised community treatment and recall patients to hospital if needed.
• Triage wards had been used as temporary admission wards, “undermining” their potential to manage bed pressures.
• Patient discharges from triage wards were obstructed by a lack of supported accommodation placements to go to or a shortage of beds on treatment wards.
• Patients in crisis were sent “very long distances” to out-of-area hospitals, a situation highlighted by a Community Care investigation last year.

NHS clinical commissioning groups have a legal duty under section 140 of the Mental Health Act to designate a hospital where patients can be admitted to in “cases of special urgency”. The CQC said evidence gathered by its Mental Health Act commissioners and prior research by The College of Social Work “suggests this duty is not being met in many areas”.

Heather Hurford, the CQC’s national policy lead for the Mental Health Act, said the regulator had “strengthened” its message to commissioners.

“It is increasingly clear to us that there is a limit to what providers can do if they don’t have commissioners supporting them,” said Hurford.

“There is clearly an issue in ensuring that both at a national level and at a local level CCGs and others responsible for commissioning, particularly in local authorities, work together to do joint strategic needs assessments in the way they are supposed to and focus on mental health as much as they do other areas of care.”

Geraldine Strathdee, clinical lead for mental health at NHS England, said it was clear that “local factors” were influencing use of the Mental Health Act in some areas.

“This is an extremely important and sensitive subject and NHS England is committed, with partners including service users, communities, practitioners and commissioners, to developing a greater understanding of the reasons for England’s patterns of detention using the Act. We are also putting in place new requirements to improve data quality, strengthen governance and promote a clinical focus on those who are repeatedly detained,” said Strathdee.

Ruth Allen, chair of The College of Social Work’s mental health faculty, welcomed the CQC’s emphasis on the need to improve crisis responses and commissioning.

“It’s positive to see the report taking on board the concerns raised by AMHPs and the fact that they are often left with few options when trying to pursue a least restrictive option. But if the options aren’t there, if the community support isn’t there, then we do seem to be seeing AMHPs having to organise admissions,” said Allen.

“The increase in detentions under the Act is a national human rights issue. It will be interesting to see the outcome of the research that is being done into the reasons behind that rise. There may be good and justifiable reasons for it but we don’t know yet and it does feel like the pressure on crisis services and the pressure on community and preventive services is playing a part.”

Paul Farmer, chief executive of mental health charity Mind, said:

“There are obvious pressures on the system, which are having a significant impact on the care of people who are at their most unwell. Increasing bed shortages and staffing difficulties resulting from cuts to mental health services over two consecutive years mean people aren’t getting the help they need. We are concerned at the evident lack of therapeutic activities available on some wards – it is essential that services focus on recovery rather than simply containing people who are in crisis.”

The CQC said that the government’s forthcoming ‘crisis care concordat’ would set expectations on agencies to “ensure the quality of response in crisis situations when people with mental health problems urgently need help”. The CQC will also publish a national report on access to crisis care in the Autumn.

Out-of-hours and inpatient care

The CQC’s report also found a number of problems with out-of-hours and hospital care. Specific concerns include:

• Cuts to AMHP numbers at one local authority had left “too few AMHPs to provide a safe service”.
• Services reported difficulty accessing AMHP support out-of-hours. Services in London reported waits of over four hours for AMHP support. A common reason cited for the difficulties was that emergency duty team AMHPs who covered both children’s and adults services could get “tied up” with child protection cases.
• Patients that had been admitted to wards voluntarily, rather than under the Act, were subject to ‘de facto’ detentions – situations where staff said they would detain patients under the Act if they tried to leave.
• Hospitals had imposed “unacceptable” blanket rules on patient access to the internet and outside areas. Such practices “have no basis in law or national guidance”, the CQC said.
• Social care input in hospital care had been cut back in some areas, leaving patients and relatives with no named individual to coordinate their social care.
• The CQC identified a lack of discharge planning or patient involvement in more than a quarter of care plans it reviewed.

The CQC’s Hurford said that while several issues identified in the report stemmed from resource issues, there were a number of areas of care that providers could improve on without additional costs.

“That category, very broadly, is about involving people in their care. That’s something that we have flagged repeatedly. That’s actually at the heart of concerns around care planning, concerns we raised about restrictive practices, the concerns around consent to treatment, it’s all about involving people in an appropriate way. That can be cost neutral,” she said.

The CQC said it had also identified some “examples of outstanding care”. The regulator said it had found a “considerable improvement” in the provision of advocacy services for patients, which was now available on “almost all wards”. Improvements had also been made in helping patients draw up advance statements of their preferences for care.