The evidence of a massive increase in people in need of help from mental health services in the UK is now incontrovertible. NHS England reports 1.4 million people on the waiting list for care, with an additional eight million who would benefit from care, but who do not meet current criteria.
Funding?
Despite all the evidence in view, mental health services have received a small proportion of the extra funding from the government, with the vast majority of the extra funding going to tackling waiting lists for elective surgery.
What money mental health services have received has gone to community services, such as helplines, and mental health support teams in school. Some money has gone into acute inpatient services, but to convert dormitory accommodation to single rooms, which although much needed should really have been carried out years ago and does nothing to increase capacity.
Capacity?
In short, despite being under intense pressure for beds (see the Lowdown article: Mental health: data backs up concerns over services), NHS mental health services capacity has remained relatively unchanged over the past two years; as a result the massive increase in need can not be met by the NHS.
As a part of a policy to move mental health services into the community, NHS mental health bed numbers have fallen from 23,208 in September 2011 to 18,179 in September 2019 before the pandemic began. Over the pandemic, capacity has changed little and stood at 18,493 in September 2021.
Privatisation
This reduction in NHS capacity over the past decade, despite an increase in need, meant that the NHS had already been forced to turn to the private sector even before the pandemic began. In 2020 the private sector had just over 9,000 beds, the majority of which are used by the NHS, under contract. The income of one of the leading companies in the sector, Cygnet Healthcare, is entirely from NHS contracts and most companies in the sector gain the majority of their income from the NHS.
Private sector cuts beds
Now with the massive increase in need for mental health services and the lack of any investment in increasing NHS capacity, the NHS has become even more reliant on the private sector. However, companies are facing difficulties in recruiting qualified staff, at the same time they have reduced bed numbers – limiting the risk of issues with the standard of patient care and negative reports from the Care Quality Commission (CQC).
A report in the FT notes that despite a sharp increase in need, the private sector is cutting beds for children, with it notes about 325 beds removed in the past five years, which leaves just 1,321 beds for children and teenagers in England.
The Priory, the UK’s largest private mental healthcare provider, told the FT that the closures of beds were “the result of having to address a sector-wide shortage of specialist child and adolescent clinical staff” and reducing beds enabled the company to maintain standards and deliver the care expected by the CQC.
The past two years have seen a number of hospitals run by private companies castigated by the CQC, particularly in the area of CAMHS. The two leading companies, The Priory and Cygnet Healthcare, have both had to close wards as a result of damning CQC reports and St Andrews Healthcare the leading not-for-profit in the sector has had severe limitations put on its services due to CQC reports.
A major issue is the difficulty in getting appropriate staff – the CQC reports have often focused on staffing issues and many incidents have hit the headlines of terrible staff behaviour.
St Andrews Healthcare, the leading not-for-profit, in the sector has significantly scaled back its CAMHS services and announced plans to sell its Mansfield site to Nottinghamshire Healthcare NHS Foundation Trust.
The issue of staffing is not restricted to CAMHS wards, CQC visits to St Andrews Healthcare’s hospital in Northampton last year led to it being prevented from admitting new patients to some wards without prior consent from the CQC. Short-staffing was a major issue plus not all staff were suitably qualified or competent for their roles. St Andrews was told that it must ensure adequate staffing levels and provide staff with appropriate training for their roles.
Shrewsbury Court Independent Hospital in Surrey run by the Whitepost Health Care Group, closed in December after the CQC imposed urgent conditions requiring rapid improvements at the site. It provided long stay and rehabilitation services for people with mental health conditions, plus a learning disability and autism service. The Whitepost Health Care Group, took the decision to close the hospital due to “a combination of ever-increasing pressures within our sector, operational demands, the age of the building, and challenges with recruitment.”
There is some logic in cutting bed numbers, so that the staff the companies do have are sufficient for the number of beds and the short-staffing issue is solved, but with the NHS so reliant on the private sector, there are concerns that any reduction in beds will mean the private providers will charge the NHS higher fees for care, which costs between £500 and £1,300 a bed a day.
Travelling further for care
The government has already missed targets for reducing the number of OoAPs (Out of Area Placements) and a reduction in bed numbers in the private sector will make any reduction harder still. With OoAPs there are concerns about the quality of care provided; the disruption to individuals and their families; and the high cost of such care. Lack of investment in NHS beds has also led to the treatment of some patient groups being almost entirely reliant on private companies, with a high number of OoAPs.
A recent report from the British and Irish Group for the Study of Personality Disorder found that due to lack of investment in NHS capacity care for patients with personality disorders appears to have been fully privatised and this has a negative effect on patient care. The report is the first to look specifically at the use of OoAPs for people with a personality disorder diagnosis and although hampered by a lack of information forthcoming from CCGs, Keir Harding one of the reports authors writing in the HSJ noted that:
“The report found that OoAPs were provided almost exclusively in the private sector. With less than 50 beds for this client group in the NHS, it can be argued that with no consultation or planning whatsoever, we have privatised inpatient care for those who have lived through trauma”
The report also noted that these privately-run units can call themselves a “Specialist Personality Disorder unit” often have nothing to back up these claims and they can not be rated easily as there are no set criteria. Harding noted that “the testimonies of people who have been in such units in the report describe conditions akin to Winterbourne.”
The report also found that the market for such units is dominated by the two leading private companies, The Priory and Cygnet Healthcare. With the places so sought after and no additional capacity being opened by the NHS, this group of patients is unlikely to receive the care they need and deserve.
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