CQC calls for urgent improvements in mental health services in England

30 January 2013

Mental health services must do much more to ensure that the care they provide for detained and non-detained patients in mental health hospitals is based on individual needs.

Speaking at the launch of the Annual Mental Health Act Report last night at the House of Commons, the Care Quality Commission’s (CQC) chief executive David Behan said “People who need treatment in hospital for their mental health should have care and support to help them recover.  Some hospitals are doing a very good job in treating people with dignity and respect – so we know it’s possible.  However CQC is concerned that some hospitals have allowed cultures to develop where control and containment are prioritised over treatment and care.

 “This applies as much to detained patients as well as to those who are receiving treatment on a voluntary basis. In fact it is even more important people can be compulsory treated– greater attention needs to be paid to ensuring as much dignity and choice as possible is promoted. Boards, providers and commissioners of service need ensure that the proper safeguards and care practices are available to patients.

 “Our report has found too many instances where people have been restricted inappropriately. It is unacceptable for the current situation to continue.

 “All patients whether detained under the mental health act or not, need to be involved in their own care and consulted on their own wishes and desires. Clinical staff must be trained in assessing and recording patients’ capacity and consent.

“We will be making mental health a high priority this year and the information gained though our Mental Health Act visits and from other strategic partners will direct our inspection work. Where we witness poor and unacceptable care we will use all the powers that we have to ensure that these practices change.”

Charles Walker MP (who hosted the launch event) commented:

“We need acute settings that are entirely geared around supporting people back into recovery and wellness. Hospitals must be a place of safety and support if this is to be achieved.”

The report identifies areas of poor practice where people have not been involved in their own care. During inspection visits to detained patients, CQC noted that:

• None of the patients they interviewed knew what was in their care plan.
• None felt involved in planning their care, or in any decisions made about their treatment.
• None knew what the plans for discharge were, or what they had to do to prove that they were ready for discharge. This ranged from a patient not knowing that he was detained to two other patients both wondering what it was that they had ‘done wrong’ to warrant being locked in hospital.
• CQC found locked wards where there were no visible notices or other information for non-detained patients to indicate how they could leave the ward if they had the desire to do so.
• The ward manager in one hospital was asked what would happen if an informal patient wanted to leave the ward. She said that she would use a holding power to stop patients leaving the ward.

However, CQC has also witnessed a great deal of respectful and compassionate professional practice.  The report highlights examples of good practice and the CQC is urging providers to learn from what works well. examples include:

• CQC witnessed patients being fully involved in planning their own care and treatment, and provided with the tools to make such involvement meaningful.
• Issues raised with CQC by individual patients were discussed with staff on the day and the outcome agreed with each patient.
• Patients felt that staff listened to them, treated them with respect, explained  treatments to them in full and sought their opinions and views about their care at all times.

Analysis of the findings from the report show thatthe number of people subject to the Act is rising (those detained as inpatients and those subject to Community Treatment Orders). This means there needs to be a greater focus on the human rights of people who are being detained and treated on compulsory basis. This concerns the CQC, but also should be the focus for organisations providing care and treatment, commissioners of services, and the general public.

The findings from the report show:

• Services are under pressure, for example issues relating to provision of Approved Mental Health Professionals and transport to hospital, high bed occupancy, increased workloads and access to psychological therapies.
• Some improvements have taken place since 2011 but most of the concerns highlighted in previous reports remain, particularly in respect of care planning, patient involvement and consent to treatment.
• There is a significant gap between practice and the ambitions of the national mental health policy. CQC observed that the policy ‘No Health without Mental Health’ was not being observed in many wards and trust that were visited.
• Concerns about cultures may persist where control and containment are prioritised over treatment and support.  In this kind of culture, ‘blanket’ coercive practices can become institutionalised.

The report concludes that:

• Care planning should reflect the recovery ethos and follow guidance   set out in the national Care Programme Approach. From a patient’s position there should be “no decision about me, without me”.
• Hospitals should continually review their polices and procedures to ensure that there is no incremental development of institutionalising ‘blanket rules’ to the detriment of patients’ rights to autonomy and dignity.
• Policy makers and commissioners of mental health services and Boards of service provider organisations have a responsibility to drive the changes that are needed in mental health provision.

Changes to the way that the Mental Health Minimum Data Set (MHMDS) is submitted and processed from 2011/12 should provide a much richer data source for analysis of the operation of the Mental Health Act. However, the greater detail now available has exposed a number of data quality issues that must be addressed before the data can realise its full potential. The Health and Social Care Information Centre is taking a number of steps to assist providers in tackling issues with their submissions, and CQC calls on providers to ensure that their use of the Act is being entered correctly in routine MHMDS submissions.

Ends

Notes to editors

• CQC is responsible for protecting the interests of people who are subject to the Mental Health Act, by monitoring how mental health services in England – in both the NHS and independent (private) sector – are using their powers and fulfilling their duties for patients who are detained in hospital or subject to community treatment orders or to guardianship.
• CQC’s Mental Health Act Commissioners meet patients in private to discuss their experiences and concerns, make sure they understand their rights and check that staff are using the Act correctly.
• CQC also provides second opinion appointed doctors (SOADs) who decide whether the proposed treatment is appropriate for the patient.
• The number of people subject to detention under the Act is rising. In total, there were 48,631 detentions in England in 2011/12 – an increase of 5% on the previous year. A further 4,220 patients were made subject to community treatment orders (CTOs), a rise of 10%.
• Of the 4,576 patient records that CQC checked in 2011/12, 4% showed irregularities that called the legality of the detention into question. Although this is a small proportion, it means that more than 180 patients may have been unlawfully detained at the time of the visit.
• Care planning was the most frequently raised category of concern in CQC’s MHA visits. Eighty-five per cent of the care plans they examined showed evidence of individualised planning, regular review and evaluation; 15% did not. This is no change on 2010/11 and amounts to just over 650 patients where basic expectations about care planning were not met.

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