Sending acutely ill mental health patients out of area ‘increases post-discharge suicide risk’

The practice of NHS mental health services sending acutely ill mental health patients to out of area hospitals heightens the risk of suicide on discharge and should stop, experts say.

Researchers at the national confidential inquiry on suicide also recommended that crisis resolution teams should not be used as a default for patients who are at high risk or who lack social supports. Suicides of patients under care of the teams, which are used by the NHS as a home-based alternative to hospital care, increased in 2013 after years of numbers remaining relatively stable, the inquiry found.

Risk of out of area placements

The inquiry reviewed suicide and homicide data between 2003 and 2013. Researchers found that the proportion of post-discharge period suicides involving patients placed out of area increased from 6% (around 68 deaths per year) over the 2003 to 2007 period to 11% (109 deaths per year) over the 2008 to 2012 period.

Professor Louis Appleby, the inquiry’s director who was formerly the government’s mental health lead and heads-up the national suicide prevention strategy, said use of out of area placements for acute admissions should cease. Sending people away from local services was likely to disrupt efforts to put support in place for the weeks after they leave hospital, a period of “maximum risk”, he said.

“There has been a lot of focus on the distress it can cause to send people to hospitals long distances from friends and family. When you reach the point of discharge you are still a long way from home, your friends and family. You are with a service that is not your own service,” said Appleby.

“If you are a clinician you are trying to coordinate care with a service that you don’t necessarily know. There are obvious disruptions to care planning. When someone leaves hospital it is the maximum period of risk”.

Community Care research published last week suggests the number of patients sent out of area for beds rose by 23% last year, with almost 90% of placements due to local bed shortages rather than patients requiring specialist care. The use of out of area placements had already doubled between 2011-12 and 2013-14.

Mental health charity Mind said it supported the call to end out of area placements for acute admissions.

Review crisis team safety

The inquiry also calls for NHS commissioners and providers to review the safety of their acute services after finding evidence that bed pressures were impacting patient safety.

One issue was the NHS’s growing dependency on using crisis resolution teams as an alternative to hospital admission. The services, which were introduced in the mid-2000s, are underpinned by an evidence-based model of care. However, findings published from a Department of Health-funded study last year revealed that most crisis teams were not functioning in line with the model set out in official guidelines introduced in 2001.

Appleby said that the inquiry’s own research suggested the pressure on the mental health system may be leading to crisis teams being used as a default treatment option, even for patients for whom the service is unsuitable.

The inquiry found that there were 226 deaths of patients under the care of crisis teams in 2013, the highest in the 10-year period analysed. Suicides of patients who received crisis resolution support are now three times more common than suicides in mental health inpatient settings, researchers found. Around 40% of cases involve people who were living alone.

“It suggests CRHT [crisis resolution home treatment] is being used for people for whom it may not be suitable. When we looked at acute services, the pattern was one of a system under pressure. It is a picture of a service that is trying to use home treatment to absorb pressures and it is using it in a way that, for some people, is unsafe,” said Appleby.

The report recommends that crisis teams should not be used by default for patients who are at high risk or who lack other social supports. It also calls for providers to ensure the skill-mix of crisis teams and the contact time staff have with patients reflects the model’s intention to deliver “intensive community-based” support.

‘Better planning of acute care needed’

Appleby said that the inquiry’s findings are always affected by “patient flow”, and the rise in the proportion of suicides involving out of area discharges or crisis teams would partly reflect the fact more patients are being using these services.

“[However] if I was commissioning a service I wouldn’t be comfortable just attributing this to the flow. There needs to be better planning of acute care,” he said.

“This is not just an issue of beds, it’s about the way local acute services are commissioned across the system. It is not about stopping people going out of area, it’s about having the provision to absorb the problem of acute illness within your local services.”

Since April 2014, NHS England has been mandated by the government to make “rapid progress” on improving crisis services by working with local commissioners. NHS England was asked to comment on the inquiry’s findings but did not respond in time for publication.

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