Access to acute care and admission is a system problem and needs system wide solutions

09 February 2016

In his guest blog, Lord Nigel Crisp outlines the findings of a Commission to review the provision of acute inpatient psychiatric care for adults, which was set up by the Royal College of Psychiatrists in response to widespread concerns about the provision of acute inpatient psychiatric beds and alternatives to admission available for patients.

The Commission on Acute Adult Psychiatric Care was asked to review the problems of access to acute psychiatric care for adults in England and quickly came to the conclusion that access to acute care for severely ill adult mental health patients is inadequate nationally and, in some cases, potentially dangerous. It also recognised that this is a system problem and that solutions can only be found by making changes in the wider system as well as within acute care.

On average around 15% patients needn’t have been admitted if alternatives had been available, and a similar proportion of patients could be discharged if suitable services were available in the community.

Our survey of inpatient wards showed that on average around 15% - or more than one in seven - patients needn’t have been admitted if alternatives had been available and that a similar proportion of patients could be discharged if suitable services were available in the community. While these two figures can’t be added together as some patients are in both groups they, nevertheless, show that a significant part of the problem in admitting patients is caused by difficulties with discharge. The activities and capacity of every part of the system – inpatient wards, crisis resolution and home treatment teams, community teams, sheltered and crisis housing and much more – impact on all the others. Improvements in one area therefore depend to some extent on improvements being made in parallel elsewhere.

The Commission’s focus was on acute care for severely ill adults and, as these figures suggest it found that there were major problems both in admissions to psychiatric wards and in providing alternative care and treatment in the community. It is necessary to think in terms of acute care as embracing both inpatient and home-based treatment. Most versions of the “acute care pathway” do treat these two aspects of the service in an integrated fashion but it was clear that some organisations were better than others at joining them up and offering clinicians and patients real choices about treatment and care. 

Commissioning in theory should, of course, provide the overview and the means to stitch together all the diverse parts of the system so that it works effectively. In reality it frequently makes matters worse. Commissioning is spread between too many bodies, is fragmented across generalist and specialist services and is often done at too junior and inexperienced level in an organisation. Moreover, the current arrangements whereby different commissioners are responsible for different groups of services means that there can be perverse incentives and cost-shifting between payers.

The Commission saw many excellent services and was inspired and impressed by people throughout the country working hard to deliver high quality care to their patients and support to their families and carers.

Despite all these problems the Commission saw many excellent services and was inspired and impressed by people throughout the country working hard to deliver high quality care to their patients and support to their families and carers. This provides an enormous amount to build on for the future.

In thinking about recommendations, the Commission’s starting point was that mental health patients should have the same rapid access to high quality care as patients with physical health needs. Why should severely ill mental health patients – whose lives and long term health are at risk – not to be treated to the same standards as those with heart attacks, strokes or physical trauma? The Commission therefore recommends that there should be the same 4 hour guarantee for admission or treatment for severely mental ill patients written into the NHS Constitution as there is for patients visiting A&E. It also recommends that long distance transfers for non-specialist admission should be phased out by October 2017.

These improvements in access need to be accompanied by other changes to the whole system: better data collection, improved commissioning and, very importantly, greater focus on quality and the use of tested quality improvement approaches. Mental health is, of course, about people and relationships and the Commission also makes recommendations about giving patients and carers more say and autonomy – treating them in the jargon as “co-producers” with staff – and about developing leadership and management skills. It draws attention to the particular importance of good ward leadership and suggests that Trusts should review their reward and career structures to make sure that wards attract more of the best people and that they are not incentivised so that they have to move to the community to develop their career.

Improvements in access need to be accompanied by other changes to the whole system: better data collection, improved commissioning and greater focus on quality and the use of tested quality improvement approaches.

Our report paints a picture of an acute mental health system under pressure, with difficulties in access to care compounded by - in some instances - poor quality of care, inadequate staffing and low morale. Too often inadequate data and information are available but it is clear that the whole system has suffered from a steady attrition in funding from both NHS and local government sources in recent years.

National and local government need to act to redress the balance and ensure that mental health receives equal priority and funding with physical health. Commissioners and providers, too, have a responsibility to lead change, focus on quality and improve the way their organisations and the whole system works.

Most of what is needed is already being done somewhere in the country with committed and innovative people - patients and carers as well as professionals - working hard to improve services. This report’s recommendations are designed to get behind their efforts and help them to share their learning and achieve their ambitions.

 

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