Delaying admission while PCTs decide who should pay disrupts care and adds to bureaucracy. Should we look to local government for guidance? Lynn Eaton reports

Last week the biennial report from the Mental Health Act Commission revealed concerns that practitioners are being told to delay sectioning people with urgent mental health needs until they had approval for the funding of a hospital bed.

It warned: "It is improper that any hospital admission under the act should be delayed, not only by the unavoidable need to search for an individual bed, but also by an entirely avoidable requirement to ascertain its funding prior to admitting the patient."

The difficulties this might cause at a time of crisis are self-evident, and only add to the problems for patients who urgently need a bed. They also add a layer of bureaucracy to the work burden of the social worker or psychiatrist who is desperate for their patient to get the care they need.

Mat Kinton, senior policy analyst at the commission, says he cannot cite specific examples. But if practitioners report that they are being told to ascertain funding before admission - even if they are mistaken - it could lead to the following hypothetical example:

  1. A patient comes from, say, Essex, where he is registered with a GP, but is in a section 136 suite (a place of safety for assessment) in central London. The clock is ticking to find an acute mental health bed as everyone thinks that admission under the Mental Health Act is required.

  2. The London primary care trust would be prepared to admit the patient, but has no free beds anyway, and would (were this one of the London PCT's patients) resolve this using the independent sector. But it does not want to do this without a funding agreement from the PCT in Essex.

  3. The Essex PCT does not want to pay for an extra-contractual referral to the private sector as it has bed capacity, and wants the patient returned to it where it will admit him. But the London authorities do not want to spend the time or resources in conveying a patient to Essex. Essex does not want to send someone to collect the patient. The patient gets stuck in the middle.

Mr Kinton says: "The issue is more about the fact that extra-contractual referrals are being used across the service."

The lack of adequate beds in psychiatric hospitals is already well documented, with occupancy rates often running at over 100 per cent, especially in London. For social workers and doctors trying to get a patient into hospital, it means calling round to see where such a bed might be available. This will often be in the private sector. This latest scenario is just another potential hurdle to overcome.

Understandably, in the brave new world of commissioning, a primary care trust will want to establish quite firmly that the patient is, in fact, one of its own - especially if it is going to be billed for a patient's care. And if the bill is coming from a private hospital, even more so.

Pan-London agreement

In London, where merely moving five miles up the road can take you out of one PCT and into another, such issues have already been addressed. There is a pan-London agreement to treat a patient who comes from outside the PCT boundary.

Even the most diligent patient won't necessarily have signed on with a new GP, or have notified the PCT that, since they moved two streets away, they are now in City and Hackney rather than in Islington PCT - they may not even realise.

And it would be unrealistic to expect a person concerned with a serious mental health problem, whose lifestyle may be more chaotic than most, or who finds even the most basic tasks are a major hurdle, to have done so.

Who Pays? Establishing the responsible commissioner, published last September, sets out where the burden should fall in disputed cases (see below).

It also says that where a patient is being admitted under the Mental Health Act, "every effort should be made to determine GP practice registration or establish a resident address".

The Department of Health advises that where it is not possible to find out this information, "the responsible commissioner should be determined by the location of the unit providing treatment. Therefore, in this context, the PCT in which the facility is located becomes the responsible commissioner".

The DH said it was evaluating comments received on the consultation for the draft revised code of practice, which closed on 24 January.

Mr Kinton says, since last week, he has been told that nothing in the responsible commissioning guidance requires practitioners to seek funding arrangements prior to emergency admissions, which would suggest that it could be a misunderstanding by the professionals.

"It seems to me that this indicates there is a potential problem between PCTs not included within the reach of an agreement [like the pan-London one] over funding liabilities and that the scenario we described is a potential problem in current arrangements," he says.

"At the moment there's no specific reference to the Who Pays? guidance in the Mental Health Act code of practice. Perhaps the approved social workers haven't seen it, or don't know the first thing about it."

Patients come first

For Southwark PCT, which has in its catchment area the Bethlem Royal and Maudsley hospitals - and a highly mobile population to boot - the consequences of paying for out-of-London patients could be considerable.

However, a spokesperson for the trust appears a little bemused by questions on what provision they had made for people from outside London who were admitted. "Potentially the PCT would, I suppose, be picking up a large bill," he says.

And Yvonne Stoddart, director of the Care Services Improvement Partnership acute mental health project, was not previously aware of such concerns. "The needs of the patient must come first," she says. "We'd all be very concerned if we found out it was happening."

A South London and Maudsley trust spokesperson acknowledges it had been a potential issue: "We are reviewing implementation of our guidance. As far as mental health is concerned, it is difficult."

Mental Health Network director Steve Shrubb says he cannot believe that any PCT would refuse to fund a bed for someone who had been taken ill in their area and was in need of emergency care. "Why should a PCT run such a risk? Patients that are sectioned under the Mental Health Act are seriously ill."

Although the draft code of practice for the act spells out a local authority's responsibilities should one of its patients be treated in a hospital outside its boundary, it makes no reference to what should happen if a PCT disputes payment. Nor does it refer to the Who Pays? guidance.

Drawing attention to dealing with out-of-boundary patients takes the spotlight off the other factors affecting admission, says Roger Hargreaves, mental health adviser to the British Association of Social Workers.

"There's a very big issue about the shortage of beds, particularly adult mental health beds," he says. "And it's not just that, but a whole number of related problems. The number of beds available in the first place is related to the level which PCTs are prepared to fund."

But the idea of cross-border charging comes as nothing new to those used to working in local government, like Mr Hargreaves. "Local government has always worked like that. You do ask where people have come from and you don't provide services for people who are the responsibility of the council next door. PCTs are now behaving like local authorities have always behaved."

In social services, if there was an emergency situation, such as a child needing to go into care, the authority where that child happened to be at the time would act - but would always pass the case back to the child's home authority.

Funding aside, it may be more appropriate for a patient with a mental illness to return to the hospital nearest their original home - and not just because the PCT where they currently live refuses to fund them.

Could we be heading for a situation akin to the US, where they will not pick people up after a car crash unless they have the correct insurance in place? Probably not, but while there is uncertainty about the guidelines, and while PCTs are fiercely protective of their budgets, the commission's report fires a warning shot.

Who is responsible? The DH guidance

SituationPCT APCT B

Responsible commissioner

Patient not yet movedRegistered and resident-PCT A
Patient movedRegisteredResidentPCT A
Patient movedDe-registeredResident but not yet registeredPCT B
Patient moved-Registered and residentPCT B