The Care Quality Commission (CQC) has a duty as the regulatory authority under the Mental Health Act 1983 (MHA) to monitor how mental health services exercise their powers and discharge their duties when patients are detained under the MHA or are subject to community treatment orders (CTOs) or guardianship. It has further duties to provide a Second Opinion Appointed Doctor (SOAD) service, to review MHA complaints and to make recommendations for changes to the MHA Code of Practice. The 2015/2016 report is the CQC’s seventh report into its statutory activities under the MHA.
In carrying out its monitoring role, CQC’s MHA reviewers visited 95% of NHS mental health trusts, conducted 1,349 monitoring visits (95% of which were unannounced) and met 4,282 detained patients. The central focus of those visits was the experience and concerns of the patients, and the private meetings reviewers had with the patients were said to be the ‘core’ of the visits. This focus is reflected in the content of the report.
The CQC found many examples of good practice and innovative approaches to dealing with concerns highlighted in previous reports. Reviewers stressed that they met thousands of staff who were compassionate and dedicated to providing high quality patient care. However, they noted that many providers needed to improve and that there were concerns that staff were not providing patient-centred care, not fully respecting people’s rights and that patients were not being fully involved in decisions about their treatment and support. Also, in half of the wards visited there had been no training of staff or updating of policies to reflect changes in the Code of Practice in April 2015.
The report deals with the scale of use of the MHA. The number of detentions under the MHA continues to rise: the previous year (2014/2015) had seen detentions rise 10%, the highest ever year-on-year rise, to 58,399. In 2015/2016 63,622 were detained, a 9% rise. The sector is also under significant financial pressure. The CQC will be working with NHS England, NHS Improvement, NHS digital and individual providers to look at rising detention rates and what this has meant for patients.
Inspections and monitoring visits also highlighted concerns about protecting patients’ rights and autonomy:
- in 10% of cases, records showed no evidence that patients had received information about their rights under the MHA
- in 18% of cases there was no evidence that staff had reminded patients of their rights and the effects of the MHA from time-to-time, to ensure that the hospital is meeting its legal duties
- 12% of patients were not informed of their right to an IMHA.
The CQC also expressed concern about the low numbers of AMHPs and the ability of services to provide a 24-hour service that can respond effectively to patient needs, as well as a wide variation in the way AMHP services are run and reporting data across the country. In response it has made recommendations:
- for the CQC to build up an evidence base for the future development and monitoring of AMHP services
- for the Department of Health to work with AMHPs network to set national standards identifying best practice
- for new legislation to establish a new social work body which will introduce a new system of registration for individual AMHPs
- for the CQC and the Department of Health to work with NHS Digital to establish a new national dataset that allows monitoring of AMHP services and outcomes.
Monitoring and inspections revealed a number of concerns about the care, support and treatment patients received in hospital. These included:
- Discussions about consent to treatment were not always taking place i) before treatment begins, ii) as the first three months of treatment comes to an end, and iii) when ongoing treatment is reviewed. These are serious failings because not engaging with patients could be denying them the chance to contribute to their care-planning or even of giving valid consent.
- Long stay units are not sufficiently focused on the assessment and treatment of physical health problems of patients. Also, the report highlighted how services should take advantage of all available smoking-cessation support to ensure that their premises become smoke-free no later than 31 December 2018.
The section on leaving hospital revealed some significant problems that require some closer scrutiny. The CQC reported that while some services are producing detailed, comprehensive plans developed with the involvement of patients, ‘overall we continue to find issues with a worrying proportion of care plans and we urge services to look at this closely’.
During visits in 2015/2016, CQC reviewers found no evidence of patient involvement or patient views in an alarming 29% of care plans they reviewed. There was also no evidence that the patient’s views about treatment were considered in 26% of these care plans. Reviewers recognised that the nature of some patients’ mental health problems made it difficult for them to engage with the care planning process but nonetheless it is expected that services should take steps to support patients’ engagement with the process and to document those efforts. Overall, the report noted a drop (compared to the previous year) in the proportion of care plans judged in 2015/2016 to be meeting the Code of Practice expectations.
The report stressed the desirability of person-centred approach to care-planning, and an openness to co-production of care plans. It pointed to research suggesting that advance statements (which are a form of care-planning, in that they might state preferences for actions to be taken or not taken in a crisis) are leading to a statistically significant and clinically relevant reduction in compulsory admissions of adult psychiatric patients. It could be that co-production of care plans could be a very effective way of addressing the trend of rising numbers of detentions under the MHA.
Individualised risk assessments
It is crucial that patients should have care plans with individualised risk assessments, which should be updated as circumstances change (for example, taking leave from hospital). Reviewers found that 14% of care plans had not been re-evaluated and updated following a change in circumstances.
Both the English Code of Practice to the MHA and the NICE Guidance Transition between inpatient mental health settings and community or care home settings (NG53 2016) state that service providers should begin discharge planning as soon as the patient is admitted to hospital. Both documents also stress the need to listen to patients and record their views, and to engage with their carers and family members to allow patients to develop the skills to help them after their discharge. Some providers are doing this well – however, an alarming 32% of care plans reviewed during 2015/2016 showed no evidence of discharge planning. This compared with 29% in the previous year.
Mind has campaigned for a number of years on many of the issues highlighted by the CQC 2015/2016 report. As a result of our campaigning and our work with partners through the crisis care concordats in England and Wales, much progress has been made in raising awareness within government and the NHS of the need to improve crisis care. We know, however, that the quality of crisis care services in England and Wales remains highly variable, and that extremely vulnerable people continue to experience poor care, as this report shows. As such, crisis care continues to be a priority issue for our supporters, campaigners, and for people using mental health services.
Mind is concerned at the CQC findings of significant shortcomings around care planning. It is not acceptable that one third of patients’ care plans showed no evidence of discharge planning. Good discharge processes and practices, multi-agency collaboration and appropriate community provision are needed if people are to be discharged safely, to recover and manage their mental health. This has profoundly negative impacts on people, including avoidable relapses and/or re-admissions and an increased risk of suicide where people do not receive follow-up care in the period immediately after a poorly-planned discharge. This is an area in which Mind will focus campaigning efforts to ensure people experiencing a mental health crisis have access to high quality and timely care and support.
The report can be found here.