State of Care

Each year the Care Quality Commission ("CQC"), the regulator of health and social care in England, publishes its annual report, State of Care, on the state of health and social care services in England. This year the report focussed heavily on in-patient mental health services.

The CQC continues to have concerns about the safety of NHS and independent sector mental health services, with over a third rated as "requires improvement" or "inadequate" for the question "are services safe?" In terms of core service ratings, the CQC has observed a worsening in the quality of services since last year. In particular in acute wards for adults and psychiatric intensive care units. Here 6% of services were rated as inadequate (compared with 2% last year) and 38% as requiring improvement. Similarly ratings of inadequate have risen from 1% last year to 4% in wards for people with a learning disability or autism.

The authors of the report were worried about access to inpatient care and pointed to a decline of 14% in the number of mental health beds available. While this was in line with ambitions in the Five Year Forward View for Mental Health, the report observed that the reduction in beds was not being matched by community mental health provision.

Turning to particular issues highlighted by the CQC, concern was expressed that there were a number of "pinch points" in the mental heatlh care system:

• "the availability of community services for people with autism and/or a learning disability". It was pointed out that many young people being cared for in segregation on a learning disability or mental health ward were children. Many of them had not had access to the help they needed as children from health, education and care services and for many there was no care available locally to avoid going into hospital. For many again, hospital stays were needlessly prolonged because of delays in setting up care packages.
• "people not getting access to the community or inpatient care they need at the time they need it". In addition to the point made above about community health care not keeping pace with reduction in beds, the report refers to the CQC having been made aware by coroners between June 2018 and March 2019 of seven deaths of people assessed as requiring admission to hospital, but for whom no mental health bed was available. Comprehensive rehabilitation services for people with the most severe and enduring mental illnesses seem among the most stretched, with some services operating at 100% occupancy rates, leading to out of areas placements which can have a detrimental impact on patients' recovery.
• "difficulties accessing community child and adolescent mental health services (CAMHS)". 21% of community-based mental health services are rated as requiring improvement for the question "are services responsive?" and an alarming 10% as inadequate. Long waiting times for CAMHS services were observed by the CQC who pointed to issues of lack of investment and the fragmentation of organisations responsible for providing and commissioning care.

The report goes on to set out that the authors "have serious concerns about the quality and safety of inpatient care, and the impact that workforce challenges place on it. It remains our greatest concern". They point out that of the 14 independent mental health hospitals that admit people with learning disabilities and/or autism which the CQC put into special measures "issues with staffing were a common feature across a number of these hospitals". Those staffing issues included: - the staff skills mix not reflecting the needs of the people on the ward; a lack of learning disability nurses, meaning that their work is carried out by healthcare assistants or other non-qualified staff; inadequate staff training; problems with recruitment and retention; over-reliance on agency staff.

Finally the mental health chapter of the report concludes with the observation that "the landscape of mental health provision remains confusing and complex for everyone seeking mental health care". Complicated commissioning arrangements (sometimes with multiple CCGs covering the same geographical area) make it difficult for people to navigate the system.

The report is careful to highlight examples of excellent practice and observes that high quality care is being delivered by dedicated staff. But overall an alarming picture of mental health and learning disability and autism services is presented – "Increased demand, combined with the challenges around workforce and access risk creating a perfect storm. People who need support from mental health, learning disability or autism services may receive poor care from unqualified staff; they may have to wait until they are at crisis point to get the help they need; they may be detained in unsuitable services far from home; or they may be unable to access care at all."

It is gravely concerning that many of these issues are not new ones, and that some old problems are just getting worse. The new government clearly needs to make a substantial investment in infrastructure and workforce and must deliver the NHS Long term Plan in every local area to make meaningful change for people who are trying to access support.

Read the full report State of Care, or the summary of the report on the CQC website.