Mental health rehabilitation inpatient units provide an essential service for some of the most ostracised and vilified people in the country; those who live with complex psychosis and whose needs cannot be met by general adult mental health services.
Last year the Centre for Mental Health published a briefing paper on long-stay mental health rehabilitation units (Wright, 2017), which raised a number of concerns about people being placed far from home in ‘locked wards’, a lack of meaningful rehabilitation and “years of disinvestment in local rehabilitation services and a historic lack of policy to guide NHS commissioners and trusts in what is required to support successful recovery for this group” (Killaspy, 2017). Read more in Prof Helen Killaspy’s great blog.
Our blog today summarises this briefing and features an accompanying expert webinar that you can watch below. I would also recommended looking back at the Twitter discussion at #RehabPsych. Also, here are Helen Killaspy’s #RehabPsych slides (PDF) from the webinar.
In March 2018, the Care Quality Commission published a new briefing that seeks to improve the local provision of mental health rehabilitation inpatient services and minimise future use of out of area placements (CQC, 2018). The briefing set out to report back on these issues:
- How many wards and beds there are in England designated as providing mental health rehabilitation care, what type of wards these are, how many are locked and what they cost
- How many people are currently occupying a bed in such a ward and how many of these people are detained under the Mental Health Act
- How long these people have been in that particular hospital; and in hospital continuously if transferred there from another hospital
- How far these people are from their original home area and how many people are ‘out of area’
- Which commissioning bodies are funding the care of these patients and what is the extent of variation between clinical commissioning groups (CCGs) in the number of places funded and in the funding of out of area placements
- Which NHS provider will be responsible for the patient’s aftercare.
In collaboration with NHS England and NHS Improvement, the authors of the CQC briefing sent an information request (on 23 Oct 2017) to all providers that manage mental health rehabilitation inpatient services (54 NHS and 87 independent healthcare providers). The deadline for returns was 10 November 2017.
As part of the information request, providers were given the Joint Commissioning Panel for Mental Health guidance for commissioning rehabilitation services (JCPMH, 2016) and offered five options for rehabilitation ward types that might be commissioned by a CCG:
- Complex care
- High dependency
- Locked rehabilitation
- Long stay
The JCPMH does not recognise the categories of ‘locked rehabilitation’ and ‘long stay’, but they were offered because they are terms often used by providers to describe their wards.
The information request excluded wards that provide longer-stay treatment and care for people with a learning disability or for older people (most of whom had dementia) and units that specialise in the care of people with acquired brain injury.
The authors estimate that their information request generated data from 85-90% of all rehabilitation wards in England. Their analysis was of 3,721 patients on 311 wards, provided at 203 locations, managed by 134 provider organisations.
- 53% of mental health rehab beds (2,347) were in the independent sector, with the other 47% (2,050) in the NHS
- Two-thirds of the patients were men
- 11% of patients were subject to a restriction order
- 75% were detained under the Mental Health Act (i.e. in ‘locked wards’)
- Median length of current ward stay was 323 days, but patients had been in some form of mental health hospital continuously for more than twice as long (median of 683 days).
Out of area placements
- People are often in units a long way from their home
- The distance from home is (on average) greater in independent facilities (49km), when compared with the NHS (14km)
- The vast majority of patients (78%) placed ‘out of area’ are in the independent sector
- Independent sector service managers could name the Trust responsible for their patients in 53% of cases, compared to 99% of cases in the NHS.
Differences between independent and NHS care
- 75% of independent sector wards were categorised as either ‘locked rehabilitation’ or ‘complex care’, and patients in theses units were there for longer (median 444 days) compared with 230 days in the NHS
- Longer stays equal higher costs, and this was borne out with patients in the independent sector having placements that cost twice as much as the NHS (median £162k compared with £81k).
Wide variations across NHS CCGs
- As of April 2018 there are 195 CCGs in England and 11 of these CCGs did not fund the care of any of the patients in the survey cohort
- The top 20% of CCGs funded 47% of all places
- The number of patients that NHS trusts had placed ‘out of area’ with another provider ranged from 0-85
- Sheffield Health and Social Care NHS Foundation Trust were the only Trust who were not named as having placed a patient with another NHS provider. A case study in the briefing explains how the Trust in Sheffield have achieved this.
Estimates in the briefing suggest that:
- Mental health rehabilitation beds cost about £535m each year, with out of area placements a large part (two-thirds) of this total cost
- The most expensive 10% of CCGs spend an average of at least £19,000 per day (£8,200 of which goes on independent sector provision, most of which is out of area).
The briefing concludes by saying:
In response to these findings, we have recommended that the Department of Health and Social Care, NHS England and NHS Improvement agree a plan to engage local health and care systems in a programme of work to reduce the number of patients placed in mental health rehabilitation wards that are out of area.
Strengths and limitations
The briefing authors estimate that 85-90% of all rehabilitation wards in England were included in this work, which suggests that the overall findings would not have changed very much even if there was a 100% response.
A significant proportion of data was missing for some areas:
- Home postcode (missing for 23% of patients)
- Average daily cost of wards (missing in 23% of cases)
The information request captured data from one single day at the provider site, which is assumed to be a typical day for the patients in that hospital. Projecting annual figures from this data will therefore have a wide confidence interval.
The information request did not identify the NHS trust responsible for aftercare of 24% of patients, so the results given above are likely an under-estimated of the actual number of patients for which each NHS trust is responsible.
Implications for practice
This CQC briefing provides a wake up call to Trusts and CCGs, and ultimately also to local authorities and STPs (Sustainability and Transformation Plans). The national disinvestment we’ve seen over recent years has led to a decimation of local mental health rehabilitation services in some parts of the country, which has in turn led to high use of independent sector provision. Inevitably this leads to much higher levels of expensive and unwanted out of area placements.
Of course this briefing also provides a huge opportunity for Trusts and CCGs to review all of their existing rehabilitation beds and set a clear pathway for bringing patients currently on out of area placements back to their local area. The Royal College of Psychiatrists Faculty of Rehabilitation and Social Psychiatry will be providing ongoing support in this regard. I urge people with responsibility to make changes in their organisation to read and act upon the recommendations in the CQC briefing.
Live expert webinar
Our free live streamed expert discussion featured:
- Professor Helen Killaspy, CQC National Professional Adviser on mental health rehabilitation
- Dr Rajesh Mohan, Chair of the Rehabilitation and Social Psychiatry Faculty, RCPsych
- Dr Sri Kalidindi, Past Chair of the Rehabilitation and Social Psychiatry Faculty, RCPsych
- Dr Ian Davidson, Trustwide Quality Lead at the Cheshire and Wirral Partnership NHS Trust
- Dr Mike Hunter, Medical Director, Sheffield Health and Social Care NHS Foundation Trust
- Dr Geraldine Strathdee, Non-Exec Director, South London and Maudsley NHS Foundation Trust and Former National Clinical Director for Mental Health.
We also discussed this topic on Twitter at #RehabPsych.
CQC (2018) Mental health rehabilitation inpatient services: Ward types, bed numbers and use by clinical commissioning groups and NHS trusts (PDF). Care Quality Commission, March 2018.
Wright E. (2017) Briefing 51: Long-stay rehabilitation services (PDF). Centre for Mental Health, 19 Jun 2017.
Killaspy H. (2017) Out of sight for too long. Centre for Mental Health blog, 2017.
JCPMH (2016) Guidance for commissioners of rehabilitation services for people with complex mental health needs (PDF). Joint Commissioning Panel for Mental Health, Oct 2016.