Admissions on Admissions

You may have noticed the Care Quality Commission published a report this week on the State of Mental Health Care.  Or maybe you were getting on with your life or your job, but I’ve given it as much time as I have spare and was very interested in what I read.  The CQC run an ongoing programme of inspections across the mental health trusts of England (there is a separate inspectorate for Wales) and they are also the statutory regulator for the use of the Mental Health Act 1983. This week’s report seems, to me at least, to be a overview of the individual reports they produced in their last inspection round, peppered with a sprinkling of MHA insights. I hope I understood it correctly.

As ever these days, with so many reports to read and keep an eye on, I tend to sometimes use my iPad just to search for terms within the report that will be relevant to my work.  Things as obvious as ‘police’ often through up little nuggets and so it proved with the CQC report.

Page 38, worth quoting a block of the text, if you have a spare moment! –

“There is national concern about the difficulty of finding a bed when a young person requires inpatient care. When a bed is found, it is often a long way from the young person’s home. We do not always detect this unmet need because our assessment focuses on the quality of the care provided to patients who are already on the ward, and not to those that require or are awaiting admission. However, we have received reports of the impact of the unavailability of inpatient care. This includes a letter from an assistant chief constable about a 17-year old who was kept in a police cell for 78 hours because no bed was available. The assistant chief constable commented that “the majority of this time in police custody was unlawful and it amounts to a human rights violation, given that Article 5 of the European Convention on Human Rights prevents detention by the state except in accordance with processes outlined by domestic law”.

Three things from me, on this –

  • We now have it plainly laid out that the CQC doesn’t appear to look at the admissions process – they look at the care provided once people are admitted. This makes sense of various things which have confused me for years. I have wondered why the process never seems to be mentioned in any detail as there are obviously legal issues surrounding it.
  • We can see here that senior police officers are putting it in writing to inspectorate-regulators that they believe they are being asked to inflict or endure human rights violations of vulnerable people in police custody because of delays and difficulties in securing timely admission. This mention of 78hrs is just the tip of the iceberg, I can assure you.
  • Nowhere in this report in section 140 MHA mentioned – this is the legal duty on CCGs to ensure hospitals are designated in connection with urgent admissions. It is something that was unmentioned in CQC reports for the first few years of their existence and has only recently appeared. I simply don’t know what the CQC think about any of this.

Oh, no, four things – at no place in the entire report about the state of mental health care does the report mention Approved Mental Health Professionals, the AMHPs. Simply staggering!

ADMISSIONS PROCESS

I would love to see this looked at. Everytime an AMHP fills in an application for a patient’s admission under either s2, 3 or 4 of the Act, they fill in a statutory form – they also complete an AMHP report. This means that somebody, somewhere is sitting on a goldmine of information because the two, taken together will outline when an AMHP was notified of the request for an assessment, when they secured the DR(s) to assist them in undertaking it and when the assessment took place. It will note the conclusion they reached, what the outcome needed to be and when a bed was notified to the AMHP after any assessment indicated admission. It’s all there to be reviewed – and of course, the location of the MHA assessment is recorded, so we could even examine whether any difficulties vary across Emergency Departments, police stations or community based assessments, for example in patient’s homes.

If we have Assistant Chief Constables writing to regulators with a 78hr example, does it occur to wonder how often such examples are occuring? I have recently done work on this which has formally been reported via Chief Constables to the Home Office and Department of Health.  78hrs, or just over three days detained, is just one of the lesser examples – another was 97hrs, which is an interesting number because that’s 1hr longer than the police in England and Wales may detain a criminal without charging them with something and remanding them to appear at court. And some of the examples are measured in three figures, if we’re still counting in hours, not days. If these situations do amount to an Article 5 violation – detained by the state without an obvious authority in domestic law – then how many of these situations do we have nationally in a given month or year?

Section 6(1) of the Human Rights Act 1998 prohibits public authorities including the mental health trust, the CCG, the local authority and the police from failing to ensure the Convention Rights of vulnerable people in these situations. I’ve said before and I will say again, there are two issues in domestic law that are conveniently forgotten in the creation of these situations. CCGs have a duty to ensure the health needs of their populations are met and section 140 MHA in particular imposes a clear duty to designate hospitals which can receive patients in circumstances of special urgency. How many CCGs comply with this in any meanginful way? My Freedom of Information requests suggest, most don’t comply – some don’t even know what the question means. This, in turn, creates a situation where Approved Mental Health Professionals can’t comply with their duties under s13 of the Act – the duty to make applications where the grounds for doing so are met.

We’ve had police forces threatening and starting legal action against the NHS over this, we’ve had Assistant Chief Constables tweeting publicly to pressurise managers to resolve ongoing situations, we’ve now got them writing to regulators and escalating to senior officials in the Government. I’m merely suggesting it’s way beyond time we dusted off those MHA applications and those AMHP reports and see what they reveal.  


IMG_0053IMG_0052Winner of the President’s Medal from
the Royal College of Psychiatrists.

Winner of the Mind Digital Media Award.


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7 thoughts on “Admissions on Admissions

  1. As an AMHP manager I’ve been advising AMHP s to complete a serious untoward incident (SUI) report when they are unable to make an application because of there being no bed available.
    An SUI report is also a requirement when an under 18 is on a s136 or admitted to an adult ward.
    It would be an interesting exercise to find out how, or if, these incidents are recorded nationwide.

  2. 24 July 2017

    Dear Mentalhealthcop,

    As ALWAYS, you are brilliant!

    The key issue here, then, is WHERE is the legislation that imposes these duties on the CCGs? I ask this in all seriousness bearing in mind that I have been informed that they are NOT the exact successor bodies to the old PRIMARY CARE TRUSTS that were ALL disbanded.

    Then on top of that, CCGs are often part of CLUSTERS.

    Put on top of that the radical change and transformation of the entire NHS in England with all these STPs, then mix in the legislation that imposes on LOCAL AUTHORITIES the need to provide for Health and Social Care, then we have an extremely heady mix.

    I have been reading in the HSJ whose daily email gives headline news about the NHS how we seem to be going from one crisis to another in the overall State system of welfare.

    Mental Health Trusts seem to have been regarded as the “cinderellas” of the health care system. How many PRISONS are run by Mental Health Trusts?

    I believe that the Care Quality Commission itself is in need of radical overhaul as to its remit and how it operates. It has had a chequered career and has not even been in position for very long. Rather like the PHSO, I believe it is time for radical overhaul of the CQC.

    What are your views?

    Best wishes,

    Rosemary

    1. The CCGs are different to PCTs but they absolutely did inherit the PCTs duty to designated those places, etc., for urgent admissions. Section 140 MHA was amended when CCGs were introduced to ensure this was explicit.

  3. Important blog Michael as ever – further to this point we can take this analysis one step further, namely that the source of the problem is the powerful Transforming Care Delivery Board’s (TCDB) overtly stated intention to sharply reduce inpatient beds (in which they are succeeding) it is this that has lead directly to this kind of suffering.
    Now the idea that better designed services in the community will be forthcoming is a cruel farce. The scale of the cuts to local authority budgets over the last few years has meant that far from services moving up stream, instead threshold criteria to receive services has just gone up.
    However let us just consider a further cruel irony in the system; the CQC are extremely unlikely to drill down on this issue because they formally signed away their neutrality when they signed up as a core member to the TCDB – they are officially part of the drive that causes the outcome they are not going to measure!
    I have referenced this blog and taken this issue up on mine: https://mgoldsboroughblog.wordpress.com/2017/07/24/a-cruel-irony/

  4. Firstly, thank you for all that you do Mental Health Cop.

    I have experience on the front line.

    Experience as a MH patient.

    Experience as a mother whose daughter didn’t ever get to the top of the children’s MH services for treatment before she turned 18.

    I am aghast at the lack of provisions for Mental Health services in general and concerned that this buried information is in part due to the outsourcing of care to Virgin etc.

    The situation as it stands is unfair, unsustainable and as ever put officers between the devil and the deep blue sea.

    Our PM seems to be of a mind to resolve some of these issues but there needs to be a cross party agreement now that her mandate is undermined somewhat. Lip service will not do either. A cultural shift in thinking around MH issues is required in the long run and emergency funding for the poor children banged up in a cell before being shipped off to the back end of hell is needed in the short term.

    Good luck. Will follow this closely.

    CB.

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