The Care Quality Commission (CQC) is highlighting the ongoing impact of historic and current system pressures on mental health services, their staff and the people using them.
CQC’s Monitoring the Mental Health Act (MHA) report 2021/22, published today (1 December 2022), raises concerns which have continued to escalate from previous years; mental health services and staff are struggling to recover following pressures placed on them during the pandemic and the resulting fallout.
The report stresses action is needed to resolve longstanding inequalities, particularly disproportionate use of sectioning and restrictive community treatment orders (CTO) on Black people and people from some ethnic minority groups, including those from areas of deprivation. Mental Health Services Data Set (MHSDS) figures suggesting CTO use on Black people are over 11 times that of White people.
Staff and workforce shortages have further pressured overcapacity inpatient and community services, creating significant delays in care. Gaps in community care are adding to the pressure on inpatient services, with bed availability in many services running close to or above capacity. While some services are managing to accommodate patients without extended delays, many others are struggling to provide a bed, leading to people being cared for in inappropriate environments. Tailored personal support and therapeutic activities are reduced, intensifying the potential for serious incidents, a reduced workforce compromises the service’s ability to respond to developing risks.
People, particularly those with a learning disability and or autism, are also being admitted to and remain in inappropriate environments, resulting in them not getting the care and support they need. The report cites an example of someone no longer detained under MHA but unable to be discharged from a psychiatric intensive care unit (PICU) due to external delays. Children and young people’s mental health services (CYPMH) are struggling to meet rising demand. This increases the risk of children ending up in inappropriate environments too. The report shows CQC notifications of under 18s admitted to adult psychiatric wards in 2021/22 increased 30% compared to 2020/21. To manage delays to CYPMH beds, some services invested in new health-based places of safety, to care for people while they are waiting for a ward bed.
However, good care was observed. Services were better at involving people in their care and the running of the service and using advance planning to support people’s decisions about their care. Some services actively identified a lead for promoting equality and diversity across wards, taking responsibility for ensuring the service was inclusive of people’s needs. In some services the lack of beds and gaps in community and social care has led to the development of ‘sub-acute’ wards to accommodate people whose discharge from inpatient care is delayed. Refurbished wards reflected positive effects, improving everyone’s experiences, and despite the pressures, some services were taking steps to apply the principle of least restriction to minimise incidents of restraining people.
Director of Mental Health, Chris Dzikiti, said:
“Mental health services and staff are at breaking point, with staffing shortages affecting people’s care and putting safety at risk. In some cases, we’ve heard that the lack of staff to deliver therapeutic interventions is increasing the risk of violence and aggression on wards, threatening the safety of patients and staff. While providers are attempting to put in place measures to mitigate staffing issues, the shortage of qualified mental health nurses is a systemic issue which requires longer-term national workforce planning.
“We have also highlighted inequalities in the care people receive. It is not acceptable that people from Black and some ethnic minority groups are subject to disproportionate use of sectioning and restrictive community treatment orders - providers should be asking themselves what they are doing to actively challenge this. We are also continuing to focus on care for people with a learning disability and autistic people, too many of whom are still being cared for in hospital settings far from home, away from friends and family in situations that can increase the risk of closed cultures developing.
“We continue to be concerned about children and young people’s mental health services (CYPMH), as both community and inpatient services are struggling to meet rising demand. This is increasing the risk of children ending up in inappropriate environments, such as general children’s wards. We’ve seen examples of providers and staff working hard to improve outcomes for people, adapting to workforce and demand pressures and finding creative solutions. We welcome recent funding commitments for the system and recognise work that is underway at a national level to build racial equality into mental health services and the government funded pilots testing culturally appropriate advocacy.
“There is an also opportunity to drive change at a local level with the involvement of integrated care systems, so the issues can be acted on jointly. CQC will continue to monitor the use of the Mental Health Act in services and report when appropriate.”
CQC has a statutory duty to monitor and report on how services apply the MHA to detain and treat people who have a mental illness and need protection for their own health or safety, or the safety of other people. In 2021/22 CQC carried out 609 MHA monitoring reviews. 466 wards had an on-site visit and 143 wards had a remote review. In addition CQC interviewed 2,667 patients (2,056 in private interviews and 611 in more informal situations), and 726 carers and handled 2,434 complaints and contacts from patients and others raising issues concerning the MHA.