Mental Health: Out-of-Area Placements

Lord Bellingham Excerpts

Thursday 3rd December 2015 Commons Chamber

[Norman Lamb]

My right hon. Friend makes a good point. Again, it means that we need to think afresh and innovate. The third sector has been very good at coming up with concepts such as crisis houses, where at quite low cost a facility can be provided in a locality where someone can go at a moment of crisis. They therefore might not need a formal hospital admission, and it might be a much more therapeutic place to be as they get through their crisis. I recently visited the Hertfordshire Partnership NHS Foundation Trust, which, in addition to crisis houses, has host families that someone can go to be with, if that is appropriate, for a week or however long is necessary. That might be exactly what is needed, rather than the cold, clinical environment of a hospital ward. That sort of innovation is what we need in order to ensure that we have services that meet patients’ needs.

I want to share with the House the testimony of a constituent who has experienced an out-of-area placement. It has been anonymised, for obvious reasons, but it is very powerful none the less. It is quite shocking. It reads as follows:

“I was admitted to accident and emergency at Norfolk and Norwich Hospital on a Wednesday afternoon, following a suicide attempt. I regained consciousness the following day, having been transferred to the Acute Medical Unit, and it was quickly decided that I needed to be admitted to a mental health ward.

I had previously been on Glaven Ward at Hellesdon.”

That is the mental health hospital in Norwich. My constituents continues:

“At this point I was very woozy, suffering from a dangerously low mood, and angry that my suicide attempt had failed. I was at grave risk of making another attempt on my life. Throughout the Thursday and Friday efforts were made to find a mental health bed.”

That is what happens in the system.

“My parents were frantically trying to find out what was happening, as they were desperate for me to be looked after locally. For a time we were told that I would be going back to Glaven Ward at Hellesdon, but the news kept changing between there and a unit in London.”

London is between 120 and 130 miles away from Norwich, and further away from my constituent’s home.

“I was expecting to go to Hellesdon on Friday morning, but we were then told later that day that I would be going to south London. During the Friday, I twice walked off the ward and out of the hospital, without my absence being noticed, and went down to the Watton Road”—

which is near the hospital—

“with the intention of walking in front of a bus or a lorry. The main reason I didn’t go through with it was that I did not want the vehicle to swerve into an oncoming car and cause death or injury to someone else.

Meanwhile, my parents resorted to contacting the crisis team, as they could not get any information from the bed team. A member of the crisis team took responsibility for finding out what was happening and he was able to let me and my parents know that I would be transported to south London later that Friday evening.

Finally, after more uncertainty”—

this is really shocking—

“two men arrived to take me to London. At 10 pm, feeling suicidal, frightened and confused, I got into the back of a private ambulance (which was no more than a pretty austere minibus) and was driven away from the Norfolk and Norwich Hospital. Throughout the three-hour drive, I was spoken to just once by one of the two men, and felt more like a prisoner being transported than a patient.”

That is the way our NHS deals with someone who is acutely ill. It is really shocking. It ought not to be accepted. My constituent went on:

“At 1 am, by now completely disorientated, I arrived at the front door of the mental health unit in south London. After lots of knocking at the door, someone answered, and I was handed over with a quick ‘good luck’. I was booked in and shown to my room. I felt isolated and scared. My room was nice, but the unit felt like a prison. The internal doors were like cell doors, and there was a tiny outdoor area, fringed by a high fence with spikes on the top. It was a mixed ward, both in terms of sex and in terms of illness: people with depression and anxiety were alongside those with psychosis, personality disorders and acute problems.”

It is really shocking that a whole load of people with completely different conditions were thrown together like that. It is probably the least therapeutic environment imaginable. That is about containing people, not caring for them, and it ought to be a thing of the past.

[Mr Henry Bellingham (North West Norfolk) (Con)]

I had a similar case in King’s Lynn, although I cannot go into it because it ended in tragedy, with the individual committing suicide, having previously made an attempt. Does the right hon. Gentleman agree that it is absolutely essential in such cases that there is proper monitoring and supervision of the individual, whose life is obviously at risk during such an episode?

[Norman Lamb]

It is absolutely critical that that happens —not only monitoring but proper treatment. As I will go on to describe, that is not what happened in this case.

The constituent continues:

“The following morning, I had a meeting with my named nurse. Extraordinarily, it was the only real conversation I had with him until I was discharged back to Norfolk 10 days later.”

That is not therapeutic care—it is neglect. I have asked whether there are any contractual requirements on the private provider who provided that “care” and received a substantial sum of money for it. I have been told that it was understood that there would be therapeutic care but no apparent requirement that that should be undertaken in return for a substantial amount of public money being spent on his care. He goes on:

“The care was unacceptable. It felt as though I was being kept in a holding facility, and my mental health deteriorated, with my suicidal thoughts increasing. In stark contrast to Glaven at Hellesdon, the staff were holed up in an office with a heavy steel door that you couldn’t see into. I was being checked up on every 15 minutes, as I was a suicide risk.

But I rarely had a conversation with a member of staff. My parents came down from Norfolk twice to see me, and were horrified by what they encountered—both the level of care and my deterioration. They were constantly contacting Norfolk and Suffolk mental health trust to try to get me moved back to Hellesdon. The stress made them both ill.”

That shows the impact there is on families as well. He continues:

“Thankfully their persistence paid off, and after 10 days, I was told that I was going to be recalled. I had a brief period of uncertainty, as I didn’t know whether I would be going to Hellesdon, King’s Lynn or Great Yarmouth.

Eventually, I was told it would be Glaven at Hellesdon, and I got into a taxi with a member of staff and was driven from south London to Glaven Ward.

When I arrived there, I cried, mainly through relief. I was greeted with compassion and understanding by the staff, and—after 10 wasted and expensive days—my recovery finally began.”

That experience, sadly, is repeated day in, day out across the NHS. It is a scandal that it continues. One of the things I will put to the Minister when I conclude is that I want his commitment to end this practice, because it is intolerable that it continues in this day and age.

I mentioned cost. An analysis has been done by the national confidential inquiry into suicide and homicide by people with mental illness, which, having looked at 29 providers, says that the cost of out-of-area placements went up from £51.4 million to £65.2 million in 2014-15. That is an extraordinary amount of money to spend on an unacceptable practice, demonstrating that with smarter use of the resources available it should be possible to bring that practice an end.

The national confidential inquiry also found that being treated out of area increases someone’s risk of suicide. The pattern is most apparent in England, where suicides by in-patients and patients recently discharged from hospital have fallen, although suicides following discharge from an out-of-area ward have increased. The annual number of suicides after discharge from a non-local unit has increased from 68 in 2003-07 to 109 in 2008-12. Experts have warned that mental health patients are at the highest risk of taking their own lives in the first two weeks after being discharged from hospital, and these figures confirm that. When we are talking about a risk of people actually losing their lives, surely we have to see the absolute importance of bringing this practice to an end.

I want to refer to a recent report by the Independent Mental Health Services Alliance called “Breaking Down Barriers: Improving patient access and outcomes in mental health”. It says that we must prioritise something that I have argued for consistently—the introduction of comprehensive waiting time standards in mental health so that someone with a mental health problem has exactly the same right of access to treatment as anyone else. It also says that people who end up in an out-of-area placement, sometimes a long way from home, get “lost in the system”; they are almost forgotten about. They are away from the commissioners and the normal provider, and they can sometimes languish in these centres for far too long. That, again, is completely intolerable.

The report also refers to the problem of delayed discharge. It says:

“We have found that between 2013/14 and 2014/15, the average number of days of delayed discharge per month for trusts providing mental health services increased by 22.2 per cent. This indicates that delayed discharges are having an increased impact on patients’ access to appropriate care.”

In other words, if beds are clogged up by people who are ready to leave and go home or to go to another facility, but they cannot because nothing else is arranged for them, then someone else at a moment of crisis cannot get access to a bed and is shunted off, sometimes to a place a long way from home. That is a completely unacceptable practice.

The report refers to children and young people’s mental health services. The Minister will be particularly aware of the acute concern about children being shunted off, often to places hundreds of miles away from home—an intolerable practice. I know that that has happened in the south-west, where there has been a particular shortage of beds for children. A team within NHS England undertook an inquiry that came up with recommendations for eradicating that problem. The taskforce’s report, “Future In Mind”, which we published shortly before the general election, pointed to the absolute need to care for people close to home and to have better crisis support to avoid admissions where possible. Yet the practice continues, and it must be a priority for the Minister to bring it to an end.

One of the things that “Future In Mind” sought to address is the perverse incentive that exists in the system with the awful tiering of care within children’s mental health services. If a child is put into tier 4 from tier 3 because it is judged that they need more acute in-patient care, then the financial responsibility for their care is transferred to NHS England. There is therefore an incentive for local commissioners to push them into the top tier, which is precisely the opposite of what ought to be happening. We ought to be focusing our incentives on preventing deterioration of health, not shunting people into the most acute care, too often away from home. Imagine what it must be like for the parents of, say, a 14-year-old child who is taken to a unit 100 miles or 200 miles away from home. It is really shocking, and I hope that the Government will feel the need to commit to eradicating that practice as quickly as possible.

When the issue came to my attention as a Minister, I asked my officials to provide me with data to find out what was happening around the country. I was confronted by freedom of information requests by campaigning organisations and by news reports of shocking things that were happening in the system, but I had no information on which to base my own judgment. I was told by the officials that they did not collect data on the issue. The Government are operating in a complete fog, and we have to rely on campaigning organisations to make inquiries under the Freedom of Information Act 2000.

Incidentally, I urge the Minister to use what powers of persuasion he has to argue against undermining the Freedom of Information Act. At the moment, a process is under way that runs the risk of doing precisely that. It seems to me that freedom of information is a really important way of holding the Government to account.

I was faced with having no information or data on that practice, so we initiated a process to collect such data. We have now collected those data. They are still in experimental form, but they are better than nothing. The data show that there is extraordinary variation around the country. That brings me back to the point that this is about not just extra money, but good practice. It is about learning from areas of best practice. We now discover that many mental health trusts have no out-of-area placements, but they are funded in broadly the same way as those in areas that have a persistent and unacceptable problem.

There is a three-month delay before the data are published, so the latest data are those from the end of August, but 2,198 people were in out-of-area placements at that time. We are not entirely clear about whether the drift upwards is caused by the collection of more data or by a worsening of the problem. I do not want to draw the wrong conclusion from the numbers, but they certainly do not appear to be going down.

I want to raise with the Minister the issue that the data are incomplete because some private providers refuse to return data. Under their contractual dealings with the NHS, they are obliged to return those data. When I was a Minister, I raised that matter with officials and with the information centre. Surely, it is completely unacceptable. I have no difficulty with a good private provider providing a good service, but they must absolutely play by the same rules as everybody else.

[Norman Lamb]

I agree. There should be a level playing field, which there is not at present. We now have the unacceptable situation that data are incomplete because some private providers refuse to play ball. That leaves one suspicious, because if they do not provide data about how many people are held, it is impossible to hold the system to account or, indeed, to hold such private providers to account. The Minister must find a way to hold those providers to account and to ensure that they return the data they are obliged to provide.

A horrific number of people are still sent a considerable distance away from home. In August, 501 people were sent more than 50 km away from home. Surely that practice is intolerable, given what I have said about the increased risk of suicide, the fact that it does not provide therapeutic care and that it can lead to someone being confined for 10 days at enormous cost to the public purse. It seems to me that this is the most outrageous misuse of public money.

There are areas where that problem is persistently at its greatest. In August, the Devon Partnership NHS Trust had 45 people in out-of-area placements. The caveat is that we do not know precisely where responsibility lies, and whether this is a commissioning or a provider issue. However, that is the local provider, and one would normally expect such people to be in a bed provided by the local provider. The figure of 45 people means that significantly more than one person a day is shunted more than 50 km away from home, which is outrageous.

[Mr Bellingham]

Has any analysis been done of whether the families have been contacted in such cases? It is incredibly important that one strand of support for these patients is through their families. What percentage of cases involve families being informed, having given permission for the patient to be moved?

[Norman Lamb]

We do not have that information—the data are very basic—but that matter is crucial. I imagine that communications often fall down when urgent referrals to another location take place.

I would raise another issue about families. If they have to visit a loved one 50 km or 100 km from home, just imagine the cost involved. Members in the Chamber— any of us could be in this situation—can afford to visit a loved one, but many people cannot do so. That is another reason why the situation is intolerable.

--- Later in debate ---

[Alistair Burt]

Of course it is, and I share the right hon. Gentleman’s frustration. I write a lot of letters to colleagues who express concerns and I have to signpost them to the other organisations in the health sector that have responsibility for taking particular decisions. That is quite right, because local decisions ought to be local. Clinical commissioning groups or trusts need to be responsible and accountable for what they are doing. However, I have to tell the right hon. Gentleman that it is occasionally frustrating when I feel that I cannot pick up the phone and make my own inquiry. We cannot run a system in which Ministers arbitrarily pick up cases because they are the ones we know about; there has to be a structured system. When particular things come to light, I am looking at how to use my position and the authority of the Department to make sure that something has been properly gone into—even if it is somebody else’s statutory responsibility. We in this House who remain accountable for things should be able to make sure that those statutory groups, including the CCGs, have really got a grip. I am keen to pursue that.

[Mr Bellingham]

Does the Minister agree that there is something fundamentally unsatisfactory—and, indeed, wrong—about moving someone late at night unless it is absolutely necessary for medical and clinical reasons?

[Alistair Burt]

Yes. It seems very puzzling that that should be a regular practice, if it is. That should not be the case. Of course there are all sorts of different pressures on the system, and it would probably not be appropriate to say that it should never happen, but, in principle, people who are in a state of anxiety should be moved with the maximum care, at the time that is of greatest benefit to them and their health needs.

As I was saying, it is not acceptable for people to be travelling for miles when they are acutely unwell. It is also not acceptable for staff to be spending time phoning around to find beds for their patients.

Let me return briefly to the impact of social media. A couple of weeks ago, I read in a tweet from a frustrated doctor—I hope he will pick up on today’s debate—that on that particular day no bed had been available for a woman anywhere in England. Along with the hon. Member for Liverpool, Wavertree (Luciana Berger), who had raised the matter with me, I made inquiries and found that that was not technically true; beds were available. The response from the doctor was, “You may be technically correct, Minister, but it is very difficult to find them”, and the results of my inquiries suggest that that is true. We need to establish a better system of identifying beds that may be available, because that too is part of the problem. People should not be spending time looking for beds. I have an idea about that, which I shall mention later in my speech.

I had to tell the clinician that I did not think that, technically, what he had said was true. However, I recognise that for those who are in the business of finding beds for people, it should not be as difficult as it appears to be, and I want to establish what we can do to help.

We know that the need to place people out of area, away from home, family, friends and networks, is a “warning sign” of a mental health system that is under pressure, and we know that no one wants to spend scarce resources on sending people out of area. However, we cannot look at out-of-area treatments in isolation, because they are part of the mental health acute care pathway as a whole. I welcome the interim report of Nigel Crisp’s commission, which was set up to review the provision of acute in-patient psychiatric care for adults, and I look forward to reading his final report and recommendations early in the new year.

Lord Crisp’s interim report made it clear that—as I am sure the right hon. Member for North Norfolk knows—the situation is more complex than a shortage of beds. We know that there has been a long-term reduction in the number of psychiatric beds in England, but the report suggests that in many areas there would be enough beds if improvements were made to other parts of the system and integrated, community-based services were commissioned. That very point has been made this afternoon in relation to the variability of practice. The report also made it clear that the so-called bed crisis, or admissions crisis, is a problem of discharges and alternatives to admission, and can be dealt with only through changes in services and in the management of the whole system.

As the right hon. Gentleman pointed out, that can be done, as has been demonstrated in a number of local areas. Sheffield, for example, has almost entirely eliminated adult acute out-of-area treatments, and has reduced average bed occupancy to 75% by redesigning the local system, That has included investing in intensive community treatment, and working in partnership with housing. In the right hon. Gentleman’s own constituency, Norfolk and Suffolk NHS Foundation Trust has begun to reduce its historical problem of out-of-area treatments through a combination of investing in more acute adult beds and working with commissioners to develop community and crisis resolution services.

I understand that the independent Mental Health Taskforce has spent some time discussing these issues. I hope that its report, which will be published in the new year, will be an important driver for improving mental health services over the next five years, and will address many of the key issues raised in Lord Crisp’s interim report.