Centre for Mental Health

Secure hospital beds blocked by lack of
step-down care, says Centre for Mental
Health report

1 April 2011

Prisoners in England are unable to get access to urgent hospital care because secure hospital services are blocked by a lack of community and step-down services to which to move people on, according to a report published today by Centre for Mental Health.

Pathways to Unlocking Secure Mental Health Care is the report of a review commissioned by the National Mental Health Development Unit.

It finds that secure mental health services vary widely across the country in terms of who they admit and what support they provide. With no national standards or guidance on secure care, prisoners often get assessed many times by different experts before being admitted to hospital. Most patients spend longer than a year in secure hospitals, with a lack of community support for those who could be discharged a common cause of bed blocking.

Secure services cost the NHS £1.2 billion and treat about 8,000 people at a time, mostly in medium and low-secure hospital units. Spending on secure services more than doubled between 2002 and 2010, taking up 30 per cent of all new money for mental health services during that period.

Pathways to Unlocking Secure Mental Health Care also finds that little evidence is available about the long-term outcomes secure services achieve for their patients.

The report makes 15 recommendations to make secure services more efficient and better value for money. They include the development of guidance and quality standards to improve access and outcomes across the country. This should aim to achieve a better balance between secure, step down and community care as well as more standardised assessments and admission criteria.

Secure services need to be commissioned differently. Primary care trusts currently pay for a specified number of hospital beds each year. The report says that the NHS should commission complete packages of care for each patient with clearly defined outcomes.

The report calls for improved provision for people with personality disorder, for women, for black and minority ethnic communities and for those with learning difficulties in secure services. And it says that patients' own views about the care they receive should be used routinely to measure the performance of secure services.

Centre for Mental Health joint chief executive Professor Sean Duggan said: "Secure mental health services have a vital role in diverting acutely ill prisoners to hospital and rehabilitating offenders with severe mental health problems. But the current shape of secure services is top-heavy, with too little provision of step-down and community care for those who no longer needs to be in secure beds. As a result prisoners who are acutely unwell can't be transferred because beds are blocked.

"The current NHS reforms are an opportunity to start to reshape and rebalance secure services. The way services are commissioned today fills up medium secure beds and makes it hard to expand alternative services. We need to ensure the new Commissioning Board and GP consortia work together from day one to get better value from secure services and most importantly to achieve better outcomes for the people who use them."

Jim Symington, Deputy Director, National Mental Health Development Unit, said: "Forensic practice includes some of the most challenging pathways in healthcare. Patients with complex needs require support that is therapeutic, and also safe for the wider community. This timely report calls for action in support of the cross government mental health strategy. It provides a practical focus on key questions for current policy implementation."

Carl, currently resident in a secure mental health unit, said: "I was given an absolute discharge at my last tribunal seven months ago, but due to the lack of a suitable community placement, I am still in a medium secure hospital. It costs nearly £4,000 a week to fund my stay in hospital, which is about £100,000 so far, compared with around £600 per week in the community."

Ian, currently resident in a secure mental health unit, said: "The current secure services system does not work well. There is no-one overseeing the whole of someone's stay in hospital and there are huge administrative delays in moving people from medium to low secure beds and then on into the community. Problems such as these can have a serious effect on someone's mental health and lead to feelings of hopelessness, poor motivation and disengagement with treatment, thereby lengthening stay and perpetuating the problem.

"Improvements to the way secure services are commissioned provide a golden opportunity to improve the quality of care and involve patients in setting desired outcomes and measuring performance. Secure services should provide a 'shared pathway' of care in which we have much more of a say in the delivery and monitoring of the care we receive. As patients, we have a responsibility to be actively involved in our treatment, but service providers should also have a responsibility to involve us in planning and delivering that treatment."