In a report published today (Thursday 1 March), the Care Quality Commission (CQC) has found through an information request to providers that nearly two thirds (63%) of placements in residential-based mental health rehabilitation services are ‘out of area’, which means they are in different areas to the clinical commissioning groups (CCGs) that arranged them.
‘Out of area’ placements can mean that people are often further away from where they live, further away from their families and friends and further away from the local support services that will care for them once they have been discharged – all of which can affect their onward recovery and wellbeing.
The majority (78%) of ‘out of area’ placements are with independent sector providers rather than the NHS.
CQC has found from its inspections that the quality of care in residential mental health rehabilitation services is very similar between NHS and independent sector providers.
However, CQC’s review shows that people in residential mental health rehabilitation services provided by the independent sector are, on average:
- More likely to be further from their homes than those staying in NHS services – 49km compared to 14km.
- More likely to stay there for longer – 14.5 months on their current ward compared to 7.5 months on their current ward in a NHS service.
- At a greater risk of having their aftercare compromised because the managers there are less likely to know which NHS trust would care for them following discharge – 99% of managers of NHS rehabilitation services were able to name the NHS trust that would provide their patients’ aftercare, in comparison to 53% for independent services.
CQC found that the daily cost for residential mental health rehabilitation is similar (£350 for a NHS bed, compared to £364 for an independent sector bed). However, because of the longer stays, independent services can end up costing twice as much as NHS services – average cost of current is stay £162,000 in comparison to £81,000.
CQC estimates that £535 million is spent on residential mental health rehabilitation annually, with ‘out of area’ placements accounting for around two thirds of this expenditure.
In its report, CQC has made a number of recommendations, including for local bodies – CCGs, NHS trusts and local authorities – to review how appropriate their current placements are of patients in residential mental health rehabilitation services, so that they can be confident they are fully enabling patients’ rehabilitation and onward recovery.
This is consistent with the Five Year Forward View for Mental Health (published by NHS England in February 2016), which states that people should not be cared for in restrictive settings longer than they need to be and that the NHS should expand its community-based services to support people to live safely as close to their homes as possible.
Dr Paul Lelliott, Deputy Chief Inspector of Hospitals (lead for mental health) at the Care Quality Commission, said: “Inpatient rehabilitation services have a vital role to play in supporting people with severe mental health problems to recover and return home. Collectively, the independent sector and the NHS make a valuable contribution to the delivery of mental health rehabilitation and in helping people to step back on the road to living more independently.
“However, we are concerned about the high number of beds in mental health rehabilitation wards that are situated a long way from the patient’s home. This dislocation can mean that people can become isolated from their friends, from their families and from the services that will provide care once they have been discharged.
“Also, we are concerned that our evidence shows that on average, people in ‘out of area’ placements can end up staying in residential rehabilitation for twice as long as they would have done in a local NHS bed, which can increase their sense of institutionalisation, affect their onward recovery, and can be very costly.
“The attention now must be on developing services that are focused on people’s recovery and that are not ‘long-stay’ wards in disguise, that are closer to where people live, and that are well-connected to the wider local system including services that will provide aftercare.”
Through its information request, CQC identified 4,397 beds for residential mental health rehabilitation across England – 2,050 in the NHS and 2,347 in the independent sector – with the median length of stay in their current ward being 323 days.
The services work with people with complex psychosis and other serious mental health problems, whose needs cannot be met by general adult mental health services. They enable people’s recovery and help them acquire or regain the skills and confidence to live successfully in the community.
CQC first expressed concerns about the appropriateness of inpatient mental health rehabilitation last July upon completion of its first round of comprehensive inspections of mental health services in England. At this point, CQC committed to explore the issue further and it has done so by asking providers of inpatient mental health rehabilitation to share additional information about their services. This included information about their ward, bed and patient numbers, their cost and funding arrangements, and their patient journeys (such as, how patients entered the services, how long they were there, and how far they were from their original home areas). CQC received responses from 134 of the 141 providers that it had approached.
CQC has carried out its review in collaboration with NHS England and NHS Improvement. The Secretary of State for Health and Social Care has accepted the recommendations in CQC’s report.