Last Updated on July 21, 2017

In its new State of Mental Health report, the Care Quality Commission (CQC) is warning that the mental health sector is ‘at a crossroads’. It says that some services are responding positively to unprecedented challenges but others must move away from out-dated care that leaves people ‘helpless and powerless’.

The CQC has published the findings of its comprehensive inspection programme of all specialist mental health services, giving the most complete picture ever of the quality of mental health provision for people in England.

Inspectors found many examples of excellent care – but they also found too much poor care and far too much variation in both quality and access across different services. This is particularly concerning given the increasing demand for mental health services, meaning that more people risk receiving care that is not good enough – or no care at all.

By 31st May 2017, 68% of core services provided by NHS trusts and 72% of independent mental health locations were rated as Good; with 6% of NHS and 3% of independent core services rated as Outstanding. Of the 22 NHS trusts originally rated as Inadequate or Requires Improvement that the CQC has re-inspected, 16 achieved an improved overall rating. Nearly all NHS and independent services were rated as Good or Outstanding for having caring and compassionate staff (NHS: 88% Good, 9% Outstanding; independent: 93% Good, 5% Outstanding).

However, the report identifies several areas of concern: physical environments not designed to keep people safe, care that is over-restrictive and institutional in nature, and poor recording and sharing of information that undermines the efforts of staff to work together to make sure that people get the right care at the right time.

Inspectors found that some types of service shone out: community services for people with a learning disability or autism performed particularly well; with 80% rated Good and 9% as Outstanding. In these services, inspectors found that staff were skilled and appropriately trained, patients were involved in planning their care, and there were systems in place to deal with urgent referrals.

However, looking across all care settings, the State of Mental Health report identifies several areas of concern:

• Restrictive practices. There are about 3,500 beds in locked mental health rehabilitation wards, with about two-thirds managed in the independent sector. Inspectors were concerned that some of these locked rehabilitation hospitals were in fact long-stay wards that risk institutionalising patients, rather than a step on the road back to a more independent life in the person’s home community. Another area of concern was the great variation between wards in how frequently staff use physical restraint to manage challenging behaviour. CQC is further strengthening its assessment of how and how often services use physical restraint, and will be subjecting those services where staff frequently resort to restrictive interventions to much tougher scrutiny.
• Safety. This was the area in which services were most likely to perform poorly, with 4% of NHS core services and 5% of independent mental health core services rated as Inadequate for safety and only 59% and 61% respectively rated as Good. On too many wards, the combination of a high number of detained patients who pose a risk to themselves and sometimes to others, old and unsuitable buildings, staff shortages and a lack of basic training, make it more likely that patients and staff are at risk of suffering harm.
• Patient clinical information systems. Many clinical staff told inspectors that they had difficulty recording and retrieving information that was sometimes critical to patient care, and had to work with a confusing combination of electronic systems and paper. Ineffective clinical information systems can have a real impact on people – for example, crisis teams not being able to access records for patients taken to a health-based place of safety, which could prevent people getting the care they need at the time they need it most.

Underpinning all these concerns is the fact that mental health services are under significant and increasing pressure. National figures show a continuing decline in the number of mental health nurses (a 12% fall between January 2010 and January 2017), and the number of inpatient psychiatric beds reduced by 4% overall between 2014/15 and 2016/17. At the same time, the number of detentions under the Mental Health Act rose by 26% between 2012/13 and 2015/16.

Providers have tough decisions to make, and the CQC says that there are no easy answers. However, the decisions that are right for people are often those that are right for organisations too:

• treating people as active participants in their own care promotes recovery and lessens dependence on services;
• investing in better services locally prevents the need for costly out of area placements that risk isolating people from their family and friends; whether that is for an acute admission, or to a psychiatric intensive care unit or to a locked rehabilitation ward; and
• investing in information technology that enables staff to enter and retrieve clinical information while on the move will reduce wasted staff time and make care safer.

Leadership that supports staff to work to their full potential not only increases the likelihood that people will receive good care but puts providers in a stronger position to face a future in which the scale of the challenge is unlikely to decrease.

Commissioners, too, have a responsibility to ensure that the services they are buying with public money are right for the people using them.

CQC has said that it will play its part by ensuring that everybody gets the care they need to recover – sharing best practice, driving improvement and taking action to protect people where necessary. To help do this, CQC will continue to work closely with experts in the field of mental health care to ensure that inspectors understand the latest thinking on what is a rapidly evolving area of policy and practice.