By Rajesh Mohan
The Care Quality Commission report on mental health rehabilitation services in England and Wales published in March 2018 is a real eye opener, and lays bare the grim statistics around the care of people with long term severe mental illness. The report was based on an information request to 54 NHS and 87 independent healthcare providers.
Even before the publication of the report, the Faculty of Rehabilitation and Social Psychiatry of the Royal College of Psychiatrists had expressed significant concerns about the neglect of care for people with long term and complex needs, and had raised concerns about the significant reductions in investment in rehabilitation services. They endorsed a toolkit for services and commissioners to reduce the use of out of area treatment in 2011.
Neglecting recovery based and rehabilitation services sounds extremely counter-intuitive when improving a care system. It is now well established that approximately 20% of people presenting with psychosis will go on to develop complex problems leading to long term care and treatment needs.
Neglecting recovery based and rehabilitation services sounds extremely counter-intuitive when improving a care system
We know that mental health services are stretched to the limits following years of austerity and underfunding. The demand for mental health services has only grown in this period. We have seen frantic restructuring of services to manage this increasing demand with diminishing resources. Something had to give in this system, and sadly rehabilitation services (both inpatient and community) have been one casualty.
Reduction in rehabilitation resources (including inpatient beds) has led to blockages within the acute care system at a time when rates of Mental Health Act detentions also increased significantly. Market forces have played out in this scenario, leading to an expansion of independent sector provision of rehabilitation services. It is difficult to imagine how the acute care and longer-term care would have coped if these private sector beds had not been available. Their proliferation has inversely correlated with reductions in NHS rehabilitation resources.
Something had to give in this system, and sadly rehabilitation services have been one casualty
The change led to an increase in out of area care, and the emergence of a new term called ‘locked rehabilitation’. Facilities that provide a locked model of care have long been part of the forensic care system. But there is no definition or descriptor for such services in non-forensic care. The biggest issue with this term is that it imposes restrictions on all individuals who are resident, which can include people in all stages of recovery as well as people who could be receiving treatment on a voluntary basis. CQC inspections often call out instances where there are blanket restrictions placed on individuals in psychiatric care.
The rights and wrongs of locking the doors of a psychiatric ward need a nuanced discussion. Many acute psychiatric wards have locked doors, which do not necessarily restrict the freedom of all individuals. Those who are there informally can leave the ward, and those with higher risks have ‘restrictions to liberty’ which are determined by the levels of risks and managed using individualised treatment and care plans. Such restrictions to liberty should be in place for the least amount of time necessary and proportionate.
‘Locked rehabilitation'...imposes restrictions on all individuals who are resident, which can include people in all stages of recovery as well as people who could be receiving treatment on a voluntary basis
The CQC report identified some key issues. Firstly, the numbers of people who are treated in out of area locations is staggering. They estimated that 53% of 4,397 rehabilitation beds are now provided by the independent sector. Patients in the independent sector beds were on average further away from their home address (49km) compared with NHS patients (14km). Invariably this leads to an individual’s social dislocation, which impedes recovery. One service user pointed out that in a new area often the only point of reference to their presence is “being mentally unwell and in hospital.”
Unfamiliar settings and long distances from family, friends and familiar local resources are not conducive to recovery. Indeed, social supports are so important to a person’s recovery that it is often both counterintuitive and counterproductive to be treated far from home. In addition, planning the person’s discharge is more complicated and often delayed when an individual is far from the local community services that will help support their ongoing recovery. The CQC noted that only 53% of managers of independent sector rehabilitation units could name the local mental health trust that was responsible for their patients’ community care, suggesting that they were not being proactively engaged in the process.
Social supports are so important to a person’s recovery that it is often both counterintuitive and counterproductive to be treated far from home
Unsurprisingly therefore, the CQC report found that people admitted to independent sector rehabilitation units had longer admissions (median 444 days compared with 230 days in the NHS) and were in hospital continuously for longer (median 952 days compared with 492 days in the NHS). As a result, these admissions cost twice as much as an NHS rehabilitation admission (median £162,000 compared with £81,000).
These data can be interpreted in simple terms. Drastic reductions in local NHS rehabilitation resources have led to an increase in inefficient out of area care. There is already good evidence that local ‘whole system pathways’ comprising inpatient rehabilitation beds and supported accommodation services are able to support the vast majority of people to achieve and sustain successful community discharge, without further readmissions. Given the severity and complexity of their problems and the fact that most have had many previous admissions prior to rehabilitation, this is no mean feat. Such pathways are clinically and cost-effective when provided in the right setting, and lead to successful community discharge.
Drastic reductions in local NHS rehabilitation resources have led to an increase in inefficient out of area care
There will be rare, individual circumstances when a person needs highly specialist care and, due to the small number of people requiring such care, it makes sense that this may need to be provided at a regional or even national level rather than locally. The CQC specifies ‘highly specialist inpatient rehabilitation units’ for people with very particular and complex mental health needs and co-morbidities (e.g. psychosis plus acquired brain injury, severe personality disorder or autism spectrum disorder). They are usually commissioned by NHS England although some are provided by the independent sector and individual places can be agreed by the local Clinical Commissioning Group.
There are encouraging signs that the Government is seeking to reduce and eliminate out of area care. These have already gained momentum in acute care, where the aim is to eliminate out of area care by 2021. It is now vital that we do the same for people with rehabilitation needs. Given the depletion of local rehabilitation services, we need a radical rethink of what provisions are necessary to ensure that out of area care is no longer considered appropriate for those with longer term needs.
we need a radical rethink of what provisions are necessary to ensure that out of area care is no longer considered appropriate for those with longer term needs
The annual expenditure on mental health rehabilitation beds is estimated to be around £535 million. The CQC report says that out of area placements account for about two-thirds of this expenditure. It is important that this money is more effectively utilised to provide better integrated and properly resourced services that can support people to have locally based rehabilitation. Some trusts have already undertaken significant initiatives to ‘repatriate’ their out of area individuals and offer appropriate care locally by creating specialist teams. Some areas have invested in partnerships with social care and supported housing that can meet this need.
The NHS long term plan offers a unique opportunity to get the system to work for the benefit of service users and the community by focusing on locally provided and recovery-oriented care. That means investing in skilled care teams that integrate mental health, social care and high quality and safe supported housing through effective partnerships. The NHS long-term plan must therefore ensure there are skilled multi-disciplinary community rehabilitation teams in every area and an adequate number of beds to meet inpatient care needs.
The NHS long term plan offers a unique opportunity to get the system to work for the benefit of service users and the community by focusing on locally provided and recovery-oriented care
The newly established NHS Improvement programme, Getting It Right First Time for Rehabilitation Psychiatry, also offers real promise in addressing variation in care provision across the country. It is an opportunity to improve care for all people with rehabilitation needs and to share good practice and innovation more widely. It will also give the much-needed scrutiny if any care provision fails people with long-term needs, through use of data and support using quality improvement tools to improve patient experience.
Sending vulnerable and unwell individuals to out of area settings for long term treatment, simply because services have disinvested in local services, is morally wrong. It is a national scandal both in terms of human rights and in the inefficient use of public resource. It offers no real benefits to the individual or to the local health budgets. The long-term NHS plan is an opportunity to put that right. I hope NHS England and the Government will take it.
Dr Rajesh Mohan is a consultant rehabilitation psychiatrist at the South London and Maudsley NHS Foundation Trust and chair of Faculty of Rehabilitation and Social Psychiatry of the Royal College of Psychiatrists, London.