The Care Quality Commission (CQC) today publishes the findings of its comprehensive inspection programme of all specialist mental health services, giving the most complete picture ever of the quality of mental health provision for people in England.
Inspectors found many examples of excellent care – but they also found too much poor care and far too much variation in both quality and access across different services. This is particularly concerning given the increasing demand for mental health services, meaning that more people risk receiving care that is not good enough – or no care at all.
By 31 May 2017, 68% of core services provided by NHS trusts and 72% of independent mental health locations were rated as good; with 6% of NHS and 3% of independent core services rated as outstanding. Of the 22 NHS trusts originally rated as inadequate or requires improvement that we have re-inspected, 16 achieved an improved overall rating. And nearly all NHS and independent services were rated as good or outstanding for having caring and compassionate staff (NHS: 88% good, 9% outstanding; independent: 93% good, 5% outstanding).
However, the report identifies several areas of concern:, physical environments not designed to keep people safe, care that is over-restrictive and institutional in nature, and poor recording and sharing of information that undermines the efforts of staff to work together to make sure that people get the right care at the right time.
Dr Paul Lelliott, Deputy Chief Inspector of Hospitals (Lead for Mental Health) at the Care Quality Commission said: “More than ever before, people are being encouraged to talk openly about mental health conditions and to share their experiences – and more people than ever are receiving treatment and care for mental health conditions, in part due to a reduction in the stigma associated with mental ill health. But this vital work must be supported by services that give people the help they need, when they need it.
“The mental health sector is at a crossroads. The Five Year Forward View for Mental Health, published last year, along with the newly introduced waiting time standards, point the way to a future where people have easy access to high quality care close to home and are able to exercise choice. To achieve this vision, the sector must overcome an unprecedented set of challenges – high demand, workforce shortages, unsuitable buildings and poor clinical information systems.
“Some services remain rooted in the past – providing care that is over-restrictive and that is not tailored to each person’s individual needs. This can leave people feeling helpless and powerless. But the best services are looking to the future by working in partnership with the people whose care they deliver, empowering their staff and looking for opportunities to work with other parts of the health and care system.
“These outstanding mental health services provide world-class care, whether in hospital or in the community; the challenge is how to ensure that everyone, no matter where they live or who they are, has access to services of this quality. The good news is that mental health services in England have the raw material to achieve great things.
“We have rated almost every service as good or outstanding for caring – ratings that were informed by our own observations and with interviews with many thousands of staff and patients.
“Those who deliver and commission care must learn from the services that are getting it right. And we will continue to highlight good practice, drive improvement and act on behalf of people to ensure that everyone gets the help they need when they need it.”
Inspectors found that some types of service shone out: community services for people with a learning disability or autism performed particularly well; with 80% rated good and 9% as outstanding. In these services, inspectors found that staff were skilled and appropriately trained, patients were involved in planning their care, and there were systems in place to deal with urgent referrals.
However, looking across all care settings, the report identifies several areas of concern:
Restrictive practices. There are about 3,500 beds in locked mental health rehabilitation wards, with about two-thirds managed in the independent sector. These wards are often situated a long way from the patient’s home, meaning that people are isolated from their friends and families. Inspectors were concerned that some of these locked rehabilitation hospitals were in fact long stay wards that risk institutionalising patients, rather than a step on the road back to a more independent life in the person’s home community. Another area of concern was the great variation between wards in how frequently staff use physical restraint to manage challenging behaviour. CQC is further strengthening its assessment of how and how often services use physical restraint, and will be subjecting those services where staff frequently resort to restrictive interventions to much tougher scrutiny.
Safety. This was the area in which services were most likely to perform poorly, with 4% of NHS core services and 5% of independent mental health core services rated as inadequate for safety and only 59% and 61% respectively rated as good. On too many wards, the combination of a high number of detained patients who pose a risk to themselves and sometimes to others, old and unsuitable buildings, staff shortages and a lack of basic training, make it more likely that patients and staff are at risk of suffering harm.
Patient clinical information systems. Many clinical staff told inspectors that they had difficulty recording and retrieving information that was sometimes critical to patient care, and had to work with a confusing combination of electronic systems and paper. Ineffective clinical information systems can have a real impact on people – for example, crisis teams not being able to access records for patients taken to a health-based place of safety, which could prevent people getting the care they need at the time they need it most.
Underpinning all these concerns is the fact that mental health services are under significant and increasing pressure. National figures show a continuing decline in the number of mental health nurses (a 12% fall between January 2010 and January 2017), and the number of inpatient psychiatric beds reduced by 4% overall between 2014/15 and 2016/17. At the same time, the number of detentions under the Mental Health Act rose by 26% between 2012/13 and 2015/16.
Providers have tough decisions to make, and there are no easy answers. However, the decisions that are right for people are often those that are right for organisations too:
treating people as active participants in their own care promotes recovery and lessens dependence on services;
investing in better services locally prevents the need for costly out of area placements that risk isolating people from their family and friends; whether that is for an acute admission, or to a psychiatric intensive care unit or to a locked rehabilitation ward; and
investing in information technology that enables staff to enter and retrieve clinical information while on the move will reduce wasted staff time and make care safer.
Leadership that supports staff to work to their full potential not only increases the likelihood that people will receive good care but puts providers in a stronger position to face a future in which the scale of the challenge is unlikely to decrease.
Commissioners, too, have a responsibility to ensure that the services they are buying with public money are right for the people using them.
CQC will play its part by ensuring that everybody gets the care they need to recover – sharing best practice, driving improvement and taking action to protect people where necessary. To help do this, CQC will continue to work closely with experts in the field of mental health care to ensure that inspectors understand the latest thinking on what is a rapidly evolving area of policy and practice.
The best mental health services in England provide care in hospitals and round-the-clock care in the community that is world-class. The characteristics of outstanding providers – like Northumberland, Tyne and Wear NHS Foundation Trust and East London NHS Foundation Trust – are those that display clear leadership, both at a provider and ward level, that ensure their staff have the systems in place to enable them to do their jobs properly and that shape the care they deliver around the people who receive it.
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