NHS mental health care has always existed in the shadow of physical care in terms of funding and health policy priority. Many in the past have termed it the ‘Cinderella’ part of the NHS. This neglect has been chronicled in numerous reports over the years, pointing to many problems such as poor patient safety, abuses of patient rights, poor complaint handling, unnecessary restrictive care regimens, poor patient–professional communication and poor patient satisfaction.
The same problems are repeated year after year and this is an acute cause for concern. These problems are compounded by the fact that we are dealing with a section of the population that is the most vulnerable to abuse and needs the highest level of protection. We are also dealing with a large-scale problem with one in four adults experiencing at least one diagnosable mental health problem in any given year:
‘Mental health problems represent the largest single cause of disability in the UK. The cost to the economy is estimated at £105 billion a year—roughly the cost of the entire NHS.’
The urgent need to transform mental health care provision
Unfortunately, giving priority to protection and care does not seem to be happening on the scale that it should be. There has been government recognition of the problems in NHS mental health services and a positive agenda for change has been set. However, recent reports from the Care Quality Commission (CQC) and the Parliamentary and Health Service Ombudsman (PHSO) show major problems stubbornly persist. The reports of these organisations and others serve as an important reminder to policymakers and staff of the recurrent patient safety and health quality problems in mental health care.
Setting the scene for change
The Five Year Forward View for Mental Health, (Mental Health Taskforce, 2016) set the scene for a positive transformation of NHS mental health provision. NHS England accepted all the recommendations in the report, for which it held responsibility. To support changes, an additional investment of £1 billion a year by 2020-21 was agreed with the Government.
In July 2016, NHS England published an implementation plan—a blueprint of what was going to happen to transform this care area (NHS England, 2016).
The Five Year Forward View for Mental Health highlighted the acute problems facing NHS mental health care:
‘Some people experience unacceptably poor access to or quality of care. There has been no improvement in race inequalities relating to mental health care since the end of the 5-year Delivering Race Equality programme in 2010. Inequalities in access to early intervention and crisis care, rates of detentions under the Mental Health Act 1983 and lengths of stay in secure services persist.’
Avoidable deaths and investigations into these were also discussed:
‘The quality of internal investigations can be poor, and providers are not always able to demonstrate robustly how they have learned from them and made improvements.’
The report and implementation plan appear to have been generally welcomed and set an agenda for change. An important issue is the speed of change and improvement, and whether this is taking place on the scale it needs to. When recent reports on safety and health quality in mental health care are analysed certain issues are flagged up that question the pace and depth of change and call for more concerted efforts to improve matters.
Maintaining momentum: the PHSO view
The PHSO (2018) report, Maintaining Momentum: Driving Improvements In Mental Health Care, shows cases of serious care failings in NHS mental health services. Although encouraged by the scale of ambition in the Five Year Forward View for Mental Health, it cautions that:
‘However, the challenge to NHS leaders is to make those ambitions a reality and ensure that the kind of incidents described in this report become a thing of the past.’
The report contains a number of complaint case reports received by the PHSO, which show shocking examples of patient injustice and, it argues, show a failure by local organisations to investigate complaints effectively. The complaints in the report predate the Mental Health Taskforce (2016) report but they are typical of the complaints about mental health care that the PHSO continues to receive and echo concerns flagged up by the CQC.
The PHSO states that 14 106 complaints were made to NHS mental health trusts in 2016-17, with around 65% being upheld or partly upheld by the local organisation. In 2016-17 the PHSO completed a further 352 investigations into NHS mental health trusts and found failings in 130 (37%). The PHSO identifies major themes from casework data:
Overcoming systemic problems
These are all problems that have been seen before in past reports from a variety of organisations. This raises the question of how endemic and engrained these types of failures are in NHS mental health care provision. Also, how effective will the Five Year Forward View for Mental Health be in ridding the NHS of these types of failures, bearing in mind the scale of the problem and that we are well into the third year of the strategy? The PHSO also makes this point, and asks leaders to consider ‘whether further work or investment is needed’ to meet the ambitions for mental health care.
CQC state of care
In my opinion CQC reports, like those of the PHSO, give an accurate and real-time view of what is going on at the NHS front line. The latest state of care report (CQC, 2018) analysed mental health care provision and found some good practice but also some serious failings. For the CQC, the quality and safety of care provided on mental health wards, and on acute wards for adults of working age, is an area of key concern. CQC inspections continue to find a substantial variation in the quality of care between mental health providers, and issues with access to services. The CQC found that most NHS mental health trusts are continuing to provide good care in their core services, with 70% rated as ‘good’ and 8% rated as ‘outstanding’, but on the question of safety 37% of NHS core services were rated as ‘requires improvement’ and 2% were rated as ‘inadequate’ (CQC, 2018: 78).
Overall, the CQC found a positive general trend of improvement, with 58% of the 55 NHS mental health trusts and independent hospitals that it reinspected improving from ‘requires improvement’ on the first inspection to ‘good’ following reinspection, but major concerns remain.
Monitoring the Mental Health Act
In another report, the CQC notes some improvement in the quality of care planning and patient involvement but says that there is considerable room for improvement (CQC, 2019). Provision of information about legal rights to patients and relatives is still the most frequently raised issue from visits. In many cases patients struggle to understand information on admission through illness. Quality and safety of mental health wards for adults is the greatest concern from monitoring visits. The CQC analysed 300 complaints and concerns and identified some common themes: medical treatment, medication, staff attitudes, communication, diagnosis and availability of leave.
Medical treatment and medication
There is an issue with people feeling that they have been detained unnecessarily, either, the CQC says, because they have not met the sectioning criteria or because they now feel that they are well enough to leave:
‘Many people reported that they do not know why they have been detained and often that detention was based on insufficient evidence.’
Patients also complained about the medication that they were required to take, or its side-effects.
Staff attitudes and communication
Complaints were made about poor staff attitudes. Some staff were accused of being apathetic, dismissive, inappropriate or rude. Some patients felt that their opinions about treatment regimens were ignored by staff. Some staff lacked compassion and some simple patient requests were ignored.
Communication failures is a major recurring patient safety and health care quality theme in both physical and mental health care.
Some issues highlighted in the report were patients not being involved properly in their own care, about services, not meeting a doctor or having their rights explained.
Underinvestment
In the forward to the report, Paul Lelliott, Deputy Chief Inspector of Hospitals (Mental Health), crystallises the main recurrent challenges in mental health care:
‘We have highlighted the high use of restrictive interventions on mental health wards (and the great variation in use between wards), the high number of assaults on patients and staff and the frequency of incidents of sexual assault and harassment. Underpinning these are problems with the physical fabric of wards, which are often located in old and unsuitable buildings, a lack of access to the full range of care interventions and problems with staffing—both number and level of expertise.’
Conclusion
The reports discussed here show welcome evidence of improvement in mental health care in some areas, but major systemic problems remain. Such problems as communication failings are very simple to fix but have plagued physical and mental health care for many years. Patients' rights should be respected, and they should be involved in decisions about their care. Underinvestment in mental health care has been a chronic problem and it is good to see government efforts being made to seriously address this issue. The reports discussed show the challenges that must be surmounted in mental health care if the sector is to shed its ‘Cinderella’ image.