Mental Health Matters: How 1,000 patients fell through the cracks

Last week, one of the country’s largest child and adolescent mental health services, Forward Thinking Birmingham, run by Birmingham Women’s and Children’s Foundation Trust, was rated “inadequate” by the Care Quality Commission.

The inspection report makes for concerning reading — not least because it speaks to a range of issues being experienced by other providers of CAMHS services across the country.

CQC inspectors warned there were not enough nursing and support staff to keep people using community services from avoidable harm. Nurses told the CQC that vacancies in the service impacted on people being allocated a care coordinator — and staff were leaving largely due to handling caseloads they felt were unsafe.

Some patients were allocated to therapists, but the scope of their role meant they could not care-coordinate for patients with complex needs.

This experience tallies with those on the ground across the country, and a recent National Audit Office report warned staff shortages remain the major constraint to improving and expanding services in mental health.

Despite a significant increase in resources for children and young people’s services since 2017, MHM has been told of concerns about a rise in less qualified staff and their ability to manage risk, while the NAO report notes a fifth of the CYP workforce have jobs outside the NHS.

Reports have hinted the government’s workforce plan could see thousands of apprentice doctors trained on the job, which when specifically applied to mental health may not help to allay concerns about risk. No firm plans have been announced yet, so the devil will be in the detail.

Demand outstripping capacity at Forward Thinking Birmingham meant risks were not being managed effectively, the CQC said, with one person’s assessment not updated since 2018 — despite clinic records showing changes to risks of self-harm and suicidal thoughts.

Perhaps the most worrying revelation is the trust’s discovery that more than 1,000 patients had been “lost to follow-up” within the community mental health teams. This meant staff had lost contact with the patient, they did not have a next appointment and had not been allocated a care coordinator. Some of these patients had come to significant harm, with three deaths reported.

FTB was specifically criticised for poor management of patients on this list, and the trust’s full response to the inspection can be read here. However, MHM understands it is not alone in having significant numbers of people in contact with services whose risks are not being managed appropriately and with more child referrals than ever before, the national situation is worsening.

The 2022 CQC community mental health survey found that people’s experiences “remain poor” and highlighted accessing care, crisis care, involvement in care and support and wellbeing as being “poor over a number of years”.

In the future, there will be an expectation placed on integrated care boards to help improve community services, although this will be a challenge. The NAO report reveals just four of 42 ICBs surveyed felt they had capacity and resources to oversee services. They also did not feel they have the data they needed to assess patient and user experiences.

Poor care persists 

NHS England’s long-awaited safe and wellbeing reviews, assessing care of almost 2,000 people with a learning disability or autism, have finally been published with concerning findings.

The assessments, carried out over eight months to May 2022, revealed instances of poor care, including failures to monitor weight gain which in some cases led to people developing diabetes.

There was a lack of access to outdoor space for some individuals, an overreliance on “treats” such as takeaways and snacks from vending machines without means for individuals to prepare their own meals, and a theme of “boredom”, particularly among children and young people.

Autistic people, and those with learning disabilities, have much higher mortality rates than the general population and poor care, such as that outlined above, only serves to exacerbate that premature mortality further.

Bournemouth teenager Lauren Bridges, whose inquest was abruptly adjourned last week, was admitted to psychiatric intensive care units eight times, often hundreds of miles away — despite her mother’s concerns that such environments were “chaotic, not suitable for people who are autistic” and “did not offer the support or therapy Lauren required”.

The wellbeing reviews revealed more people like Lauren were being kept in PICUs on a long-term basis, as “there was nowhere else to go”.

Yet public policy over the past decade has pledged to create places to go — with NHSE’s “transforming care” programme and government’s “building the right support” plan promising wider availability of community services.

According to the reviews, 57 per cent of people’s placements were outside their residential area — signalling a postcode lottery for community support across the country, with those sent out of area ranging from 73 per cent in the South West to 34 per cent in the North East and Yorkshire.

What the assessments have revealed is community support is still not adequate and hundreds of people are still inappropriately in hospital, more than a decade on from promises made over Winterbourne View.

There are some positives, as the reviews have prompted strengthening of care and treatment reviews and dynamic support registers, which help to determine risks to people admitted to hospital and review those risks over time.

New policies implemented from May 2023 will mean C(E)TRs are carried out more regularly and in response to changes in treatment, and will focus more on physical health. Meanwhile, dynamic support registers will need to be updated more regularly and risk assessments more thorough, using a traffic light system for risk.