An urgent review of services for people with severe mental health issues, such as psychosis and paranoid schizophrenia, has been ordered by NHS England, as concern grows over the number of individuals being let-down by services leading to their involvement in serious incidents.
All Integrated Care Boards (ICBs) have been told to “review their community services by Q2 2024/25 to ensure that they have clear policies and practice in place for patients with serious mental illness, who require intensive community treatment and follow-up but where engagement is a challenge.”
NHS England expressed concern that too many patients struggled to access care, which could lead them to harm themselves and/or others. In the accompanying letter Claire Murdoch, NHS England lead for mental health, highlighted that a patient not attending an appointment, DNA (did not attend), should never be used as a reason for discharge from care for this vulnerable patient group.
The guidance flagged up six areas where services fail:
- Lack of continuity of care and failure to join-up presentation history.
- Missed ‘red flags’ of earlier minor offending / not reflected in risk assessments
- Lack of, or poor involvement of carers or family members
- No long-term planning of care
- Poorly planned, precipitous discharges from hospital
- Failure to review treatment/medication
People with psychosis or paranoid schizophrenia are more likely to harm themselves than other people, but there is increasing concern in the number of serious incidents involving those with severe mental illness.
Valdo Calocane, who killed Barnaby Webber, Grace O’Malley-Kumar and Ian Coates in Nottingham in 2023, had been diagnosed with paranoid schizophrenia but had been “unmedicated and out of touch with psychiatric services for almost 12 months” when he carried out the attacks.
Zephaniah McLeod, who stabbed to death 23-year-old Jacob Billington and injured seven others in Birmingham in September 2020, had been diagnosed with schizophrenia but received no supervision despite experiencing delusions and refusing to take medication.
The April 2024 inquest in Swansea into the killing of Dr Kim Harrison, by his son Daniel Harrison, found serious failings in the NHS care. Daniel had escaped from hospital where he had been detained under the Mental Health Act after being diagnosed with paranoid schizophrenia.
In research published in 2022, London’s Violence Reduction Unit found that of 50 homicides analysed, mental illness was a “key factor” in 29 cases. Some killers were found to have withdrawn from treatment and others had untreated mental health problems. The researchers concluded that many of the 50 homicides were preventable, including those involving mental illness.
It is also the case that whilst numbers of general homicides have fallen in recent years, there has been a rise in the proportion linked to serious conditions such as schizophrenia-related disorders.
The NHS England guidance may outline best practice for ICBs, but it comes at a time when the services needed to treat patients with severe mental illness are under significant pressure after years of inadequate funding and investment. This includes NHS mental health services, that are struggling to cope due to lack of staff and beds and an increasing demand for care, plus local councils that provide various services, including social care and housing, that are experiencing a crisis of funding.
Despite many promises of increased funds and improved infrastructure from the previous Conservative governments, mental health services have been deteriorating for almost a decade. Council are struggling to provide services, including mental health services and suicide prevention, as they have experienced a real terms cut to the public health grant of 26% since 2016.
One of the most recent analyses of the NHS situation by the King’s Fund published in February 2024, found that the current numbers of mental health beds (17,836) are at their lowest level since data collection began in 2010/11. Bed occupancy was consistently over the recommended level of 85% , which is the point at which quality of care is at risk of being compromised.
The knock-on effect of dwindling bed numbers is that A&E visits have increased, with waits of up to 80 hours for some mental health patients. Patients are not found suitable care, instead they are admitted into inappropriate acute hospital beds meant for physically ill patients.
Although the mental health workforce has expanded since 2017, according to the King’s Fund analysis, this is not enough to meet current demand and any planned expansion of services. The sector has high vacancy rates and the push for recruitment has resulted in many more newly qualified staff and a change in skill mix of staff, for example less registered nursing staff and more support staff, which is having a direct impact on staff morale and patient care.
An analysis of CQC inspection reports shows that staffing problems are a factor in all those services rated as ‘requiring improvement’ or ‘inadequate’. This impacts on patient safety, and wider patient wellbeing.
The latest mental health services dataset released by NHS Digital in July showed that active out-of-area placements were at 805, the second highest level in five years, despite many promises over the years to phase such placements out, as they are known to be detrimental to a patient’s ability to recover.
In the recent King’s Speech, the new government announced its intention to introduce legislation to modernise the Mental Health Act, the main piece of law which sets out when people with mental health problems can be detained for treatment against their will.
This announcement was welcomed by mental health organisations as a start, but experts in mental health are hoping for much more than this. Over 30 organisations have already outlined what is needed to improve mental health services in the report To A Mentally Healthier Nation published in September 2023, which focuses on three key areas: prevention, equality and support, action in all three areas will help reduce and improve the nation’s mental health.
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