This is HSJ’s fortnightly briefing covering quality, performance and finances in the mental health sector.
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There was an icy chill in the air last week and not just from the weather.
Another cold front came from NHS England’s response to the Care Quality Commission’s report for mental health residential rehabilitation services.
Following the publication of the report last Thursday, NHS England said it was “implausible” for every clinical commissioning group to provide specialist residential rehab facilities, which was recommended by the CQC.
It emphasised that before any new uncosted demands are placed on providers and commissioners they would need to be “rigorously stress tested for their workforce feasibility, capital implications and affordability, and rolled out in a planned and clinically safe way”.
The surprise came from how sharp the tone was rather than actual content.
After all, the review was a collaboration between the CQC, NHS England and NHS Improvement and was accepted by the Department of Health and Social Care. National medical director Professor Tim Kendall – who works across NHS England and NHSI – was also involved in the discussions.
On the face of it, there seemed very little in the CQC report to take issue with. It was a thorough investigation into out of area placements and locked rehab units.
The regulator found residential rehab placements in the independent sector were nearly twice the length of similar placements in the NHS, more than three times as far away and twice as expensive. It is estimated to cost about £350m a year, with the burden mainly falling to CCGs.
Tanks on the lawn
We might never know why NHS England hit back so hard against this report but there are a few possibilities.
It could be responding to the CQC effectively parking a tank on its lawn by bundling up a report ostensibly about locked rehab into one about out of area placements.
Conflating the issues is awkward for NHS England as out of area placements are a priority in the Five Year Forward View for Mental Health and locked rehab is not.
By framing the argument around locked rehab as an out of area placements issue, the CQC could be suggesting forward view resources should be used to address it.
The regulator even said in the report that addressing the issues in residential rehab was “consistent” with the forward view.
Resource allocation is far from the CQC’s raison d’être – but flagging up care quality issues and pressing leaders to address them is.
On the other hand, it could just be NHS England digging its heels in on the argument that there should be no new priorities or targets without new resources, which is not unreasonable.
NHS England’s message seems to be: care standards should not slip due to lack of resources, but lack of resources can hold back policies to drive quality improvements.
Wrong end of the stick
In this case, NHS England might have grasped the wrong end of the stick.
The CQC said CCGs should look at how to provide local services that can better meet the needs of those who require rehab inpatient care, and sustainability and transformation partnerships should develop a repatriation plan and local service pathways.
This is not the same as demanding every CCG builds a new residential rehab unit, which is what NHS England dismissed in strong terms.
One trust that has made successful inroads into tackling locked rehab is Sheffield Health and Social Care Foundation Trust, which took devolved commissioning responsibility for the rehab budget, reassessed and repatriated patients, and used £2m of savings to set up an enhanced community team.
This model did not rely on a setting up a new specialised rehab unit or a huge amount of capital funding.
Admittedly there are barriers to rolling out the Sheffield model – the most notable being the lack of supported housing.
But it shows there is not necessarily a need for the mental health sector to invest billions in new rehab facilities. Instead, there are ways to spend the existing budgets better.