CQC on mental health care

CQC have been busily producing reports. Three have landed quite recently:

• State of Care (you can read our earlier blog here for a summary of the key points)
• How are people’s mental health needs met in acute hospitals and how can this be improved
• Mental health rehabilitation inpatient services

Mental health in acute hospital settings

Professor Ted Baker’s foreword states that how well a patient is treated in an emergency department or elsewhere in an acute hospital is often linked to the importance mental health care is given by the Trust board. He says that acute trusts must do more but they also need support from mental health trusts to develop better and more integrated approaches to care. Whilst the report looks at findings before coronavirus, he states that the findings remain relevant. He goes on to highlight that the integration of mental and physical health care is not just a matter for acute trusts and that when people are admitted to hospital to receive mental health treatment they need to be reassured that their physical needs will also be met.

The report stemmed from 105 acute inspections between September 2017 and March 2019.

In summary, CQC report that:

• Too often it was the system in which people were working that limited their ability to provide the best possible mental health care to their patients.
• There was often a lack of oversight at board level of the provision of the mental health component of care for patients.
• Every emergency department should have a dedicated room equipped to provide a safe environment for psychiatric assessments.
• Staff in acute settings are often not clear about the legal process for detaining someone in hospital. They were unclear about roles and responsibilities between acute and mental health trusts and there was confusion around when to use the Mental Health Act and when to use the Mental Capacity Act.

CQC's 12 steps to improve practice covering system wide changes, trust level changes, supporting staff and what CQC will do

These can be found in detail at pages 25 – 29. In summary they are:

System-wide changes:

• Local authorities, commissioning groups and integrated care providers need to work together to improve cross-sector planning and commissioning, to ensure that all patients have access to the physical, mental and social care they need.
• Improving system-wide pathways of mental health care requires improved aligned coding and sharing of data.
• Acute trusts should ensure that service-level agreements (SLAs) are in place with the appropriate organisations to ensure that healthcare records and sharing of information between clinicians is effortless.
• Commissioners need to ensure that people experiencing a mental health crisis are able to access meaningful alternatives to the emergency department.

Trust-level changes:

• All acute trusts need to have a mental health strategy.
• Mental health care should be considered frequently by the boards of acute trusts.
• Mental health services in acute trusts should meet nationally recognised quality standards.
• In emergency departments patients held in safe rooms must be provided with essential food, drink, medicines, and communication with friends and family.
• Acute trusts should have clear governance processes for administering and monitoring the MHA, which may be done in conjunction with a mental health trust (see pages 19/20 for more detail).

Supporting staff, the role of acute trusts, education providers and Royal Colleges:

• Training should be provided that gives staff the necessary knowledge, skills and confidence for meeting people’s mental health needs.  
• Better mental health care for patients should be provided alongside better support for staff wellbeing.

What CQC will do:

• We will continue to carry out our regulatory work and ensure we take appropriate enforcement action to help keep people safe and safeguard their human rights. We will also continue to encourage services to improve.

We have worked with clients to draft SLAs referred to above so do get in touch if this is something you would like to set up.

Other interesting points to note

• As of May all areas in England now have a 24/7 open access mental health crisis line for all ages. Where NHS 111 services are well integrated into community mental health services the benefits are clear.
• A lack of integrated computer systems between acute and mental health trusts also caused problems.
• They wrote to NHS England to alert them to findings about availability of mental health beds.
• CCGs need to take their legal duties to provide access to mental health care more seriously. Where CCGs have merged there should be clear lines of accountability to make sure section 140 Mental Health Act is adhered to.
• A reminder that CQC wrote to Trusts in August to emphasise the importance of identifying and mitigating ligature risks.
• They take breaches relating to MHA seriously and have taken enforcement action where standards of care in relation to the use of the MHA have been inadequate.
• Some medical teams viewed patients’ mental health needs as outside their remit. In some cases, patients with mental health needs were entirely disregarded and seen as someone else’s problem – whether that was their GP, psychiatric services or even the police.

Mental health rehabilitation inpatient services

Following concerns about the high number of rehabilitation beds situated a long way from patients' homes an information request was made by CQC back in 2017.  A second was sent to providers in 2019 to review progress. The information request was sent to 114 providers and 89 per cent responded. 320 mental health rehabilitation wards were identified.

Readers will find a vast array of tables, charts and maps summarising the findings.

Providers reported having fewer “locked rehabilitation” wards and more high dependency rehabilitation wards than in 2017.  The percentage of inpatient  rehabilitation beds being provided by the independent sector had hardly changed (55 per cent to 53 per cent).  The independent sector also continued to provide most of the beds categorised as “locked rehabilitation”. There were 3,622 patients occupying such beds in 2019 (a decrease of 3 per cent from 2017). CQC also found that there was little change in patients' median distance from home and patients receiving care in the independent sector were further away from home than patients on NHS wards.

Although the data only represents a snapshot they are concerned that:

• There had only been a small increase in the number of people receiving rehabilitation care close to home
• Too many people continued to be sent far from home for treatment
• People being cared for by independent providers were still staying longer in hospital, and were further away from home, than those in NHS services
• A high number of wards continued to identify as "locked rehabilitation" – this is against the least restrictive principle and potentially represents a breach of human rights.

At page 21 they set out their recommendations for commissioners, NHS England and for CQC itself. The recommendations for commissioners consists of seven questions that commissioners should use when planning for the provision of appropriate local mental health rehabilitation services.