This is HSJ’s fortnightly briefing covering quality, performance and finances in the mental health sector.

Feedback and comments are welcome, so please feel free to email me in confidence.

New year, same problems

It may be a new year, but the NHS, and the mental health sector particularly, face the same old problems around money and workforce, which are so closely entwined that it is almost impossible to separate them. 

Expect a focus on eliminating out of area placements after NHS Improvement added inappropriate out of area bed days to its regulatory regime. It is right to get tough on the “indefensible practice” of sending patients potentially hundreds of miles away for treatment.

But there is another practice that many, including the Care Quality Commission, believe is equally indefensible that could become much more prominent this year.

The placed and forgotten

It is commonly known as “locked rehabilitation” and is not a recognised service model by the Royal College of Psychiatrists or the Joint Commissioning Panel for Mental Health.

It refers to when patients are released from inpatient units but then placed in locked rehabilitation units – sometimes for months or even years at a time. These are often in the independent sector and it is estimated to cost the NHS millions of pounds a year.

The CQC said it was “particularly concerned” about the practice in its State of Care in Mental Health Services report last year. Inspectors were concerned that the locked units were being used as long stay wards that risked “institutionalising” patients. The report added: “We do not consider that this model of care has a place in today’s mental health care system.”

But we don’t know exactly how much it costs because many of these patients are placed in locked rehab units and then forgotten. Sometimes it is funded by NHS England out of its specialised commissioning budgets, at other times it falls to clinical commissioning groups to fork out for placements that can cost up to £130,000 a year.

This mixed commissioning, which the CQC said can also be carried out by local authorities, means it is difficult to know the extent of the issue.

HSJ understands that the CQC is carrying out a review of locked rehab and is due to report back later this year.

Many in the sector will be keen to see what it finds. In a report last year, the Centre for Mental Health said it was “vital” to have a clear definition and statement of purpose for such services to “ensure that locked rehabilitation is not just developing out of a need for cheaper low secure care”.

It is likely the CQC’s report will form the basis of a new strategy to tackle locked rehab, but as things stand it is not clear what this will be. HSJ understands that NHS Improvement was interested in addressing locked rehab too and it has the potential to take a similar position as it did with out of area placements by adding it to its regulatory framework.

But with a new chief executive taking the helm at the regulator, it is not clear if this will still be a priority.

Also, with so little data on locked rehab available currently, it will take a while to get an accurate picture of the extent of the issue and for providers to begin to report on how many patients are being placed in locked rehab and where.

What I can say is expect the “locked rehab” to appear more often in policy conversations this year.