Mental health services are very unlikely to see any of the £15 billion in funding announced by the government in the first week of September, according to sources reported in the HSJ, despite NHS England’s estimates of around 10 million people who would benefit from these services. The money is earmarked for reducing the backlog in elective surgery, so once again mental health services takes second place to physical health.
Not only do mental health services lag behind in funding, it is probably the area most reliant on private companies to provide services. As the NHS’s capacity to deal with demand for mental health services, particularly inpatient services, fell over the years, private companies have been given substantial contracts to provide much of the inpatient care needed. So any money mental health services receive is in part paid to private companies in the business of making a profit out of caring for some of the NHS’s most vulnerable patients.
Yet the standard of care provided by some of these providers has been the subject of repeated criticism by the Care Quality Commission (CQC). Two of the leading companies are Cygnet Healthcare and The Priory, both of which receive millions from the NHS and local authorities each year.
Let’s look at Cygnet Healthcare, which in 2020 received almost all of its £456.3 million in revenue from public organisations – the NHS, clinical commissioning groups, and local authorities.
The company, which is owned by the giant US corporation Universal Health Services Inc (revenue $11.6 bn in 2020), has around 140 facilities in the UK (primarily in England) providing a range of inpatient care and outpatient services, including acute care, mental health rehabilitation and recovery; personality disorder; CAMHS; eating disorders; learning disabilities; autism spectrum disorder; supported living; and nursing homes.
Cygnet Health Care has 15 provider companies registered with the CQC, but there is a single executive board and senior leadership team for all the 15 registered providers. As a whole the company provides approximately 734 beds across their social care services and approximately 2,130 beds across their health care services.
The company deals with thousands of vulnerable patients across the country each year, however several of its facilities have been rated either ‘requires improvement’ or ‘inadequate’ by the CQC over recent years and reports from the CQC have been damning, particularly of Cygnet’s management.
In June 2021, the CQC published a review of how Cygnet Healthcare was performing in terms of management – also known as a ‘well-led assessment’. The review followed-up on a 2019 review triggered by the Whorlton Hall scandal (although Cygnet did not own this hospital at the time of the scandal).
In the 2019 review published in January 2020, the CQC told Cygnet to take “immediate action” to improve its management following an investigation of the company and its hospitals. The CQC found that Cygnet-run hospitals were more likely to use seclusion and physical restraint on patients than other NHS providers of mental health care. The incidents of self-harm and assaults by other patients were also much higher. The CQC report also found that checks to ensure directors and members of the executive board were “fit and proper” were not carried out. The full-scale review was triggered by a BBC Panorama report in May 2019 into Whorlton Hall, a centre for people with learning disabilities. As a result of the programme ten people were arrested for abusing patients.
The new 2021 review revisited the 2019 concerns and also considered additional concerns that had been raised at 13 Cygnet services during inspections at services since 2019, including ongoing serious incidents, whistleblowing contact and safeguarding concerns.
Some of the most damning conclusions to come from the 2021 review once again concerned the management within the company. The CQC found that the company did “not have a longer term strategic plan” and “members of the senior leadership team were not able to articulate which groups of service users they were planning to support in the future and how they would ensure they had the appropriate estate and skilled staff to meet their needs. ” A consequence of this management approach, noted the report, was that “Cygnet had continued to close and ‘repurpose’ services and at times this took place with short notice and in response to serious concerns,” which had an adverse impact on the care of service users and caused distress to patients.
From October 2018 to January 2020, 10 of Cygnet Healthcare’s hospitals were rated “inadequate”. However, in 2021 alone the CQC has rated seven of Cygnet’s facilities as ‘requires improvement’ and three as ‘inadequate’, plus Cygnet Appletree Hospital in Durham, which has not received a rating but was given an urgent enforcement notice and restricted patient admissions.
The Appletree Hospital provides services to female patients needing inpatient mental health care. The hospital was found to have “ineffective leadership” and there were concerns over bullying and “inappropriate” restraint. The CQC had also been told of concerns of under-reporting of safety incidents and safeguarding issues, high use of intramuscular medication on patients, and incidents where medication was administered at higher levels than prescribed.
In September 2021 the CQC rated Cygnet Views, the company’s hospital in Matlock as ‘inadequate’. The hospital cares for up to 10 women with learning disabilities and complex mental health needs. The CQC report is damning of the hospital, noting that patients did not always receive safe care, good practice was not followed, and staff were not trained adequately. The report also criticised the hospital management. Earlier in the year in July 2021, Cygnet Hospital Hexham was rated ‘inadequate’ and in August 2021, Cygnet Wast Hills was rated ‘inadequate’.
Over 2020 alone, numerous CQC inspections led to ratings of ‘inadequate’ or ‘requires improvement’. The inspection reports often mentioned an issue with management.
An unannounced inspection by the CQC at the company’s CAMHS at the Godden Green hospital in Kent in October 2020 identified serious concerns about environmental risks and staff’s ability to keep patients safe from harm and injury. The inspectors found that the staff had no experience of working with young people and lacked training. They did not always treat patients and young people with compassion and kindness, nor always respect patients’ privacy and dignity. The CQC had received complaints from other professionals and relatives.
Inspectors found a culture of negativity had developed among some staff, with patients referred to as ‘difficult’ and ‘troublemakers’ in records. As a result of the report, Cygnet decided to close the CAMHS service and focus on adult patients at this hospital. A follow-up inspection, however, found that there were still problems and rated the hospital ‘requires improvement’.
An inspection of Cygnet’s hospital in Colchester in October 2020, led to the CQC telling the hospital it must remain in special measures as improvements were still needed. The inspection followed reports relating to the safeguarding of patients and the reporting, investigation and management of incidents. A more recent inspection has now rated the hospital as ‘good’.
In September 2020 the CQC carried out an unannounced inspection of Cygnet Yew Trees, a 10 bed facility for women with learning disability. The CQC reviewed 21 episodes of closed-circuit television footage and found nine that showed staff “abusing patients, acting inappropriately or delivering a poor standard of care”. Managers suspended eight permanent members of staff from working at the hospital. Referrals have also been made to the police. However, once again, the CQC criticised Cygnet’s management for allowing a culture to develop at this hospital which led to people suffering abuse.
And there are numerous other reports by the CQC into Cygnet’s facilities in earlier years.
After each inspection report and rating of ‘inadequate’ or ‘requires improvement’ Cygnet is issued with a comprehensive outline of where it has gone wrong and what it needs to do to improve. In some cases admissions are restricted, further visits are made, more reports produced. Yet, the failures keep happening. Whatever the CQC does appears to be having little effect on Cygnet’s management style and its hospital culture and on the failures of care.
Such was the level of failures that in April 2021, a letter was sent to Cygnet management by Claire Murdoch, the national mental health director, and John Stewart, national commissioning director, which HSJ reported warned Cygnet that “patients deserve better” and they will “not hesitate to take further action” if improvements are not made. The letter noted their concern and disappointment with regard to the repeated service failures and that they are not decreasing in number. The letter also noted that NHS England had been meeting with senior management in Cygnet since February 2020 to address the issues. Cygnet’s CEO is Tony Romero and the company has an advisory board that includes former Royal College of GPs chair, Clare Gerada, and Lord Patel of Bradford, who chairs England’s social work regulator.
Whether things will change following the letter, only time will tell as there is a several month lag between inspection and report publication. If things do not improve, what can NHS England and the CQC do? The CQC has issued warnings and restricted admissions, but with capacity so low for inpatient mental health services and demand escalating due in part to the Covid-19 pandemic, closing facilities could make things very difficult for the commissioners of services. Closures could mean more patients being sent miles away from home for treatment, something that services have been working very hard to reduce in recent years.
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