Analysis: Mental health services with the biggest leadership and safety risks

Leaders in the sector have warned that services with the poorest performance in these areas are the ones where it its hardest to recruit permanent staff and demand is rising.

Our analysis of all the Care Quality Commission ratings of mental health services of NHS and private providers shows there is a statistically significant correlation between leadership, quality and patient safety.

HSJ reviewed the CQC ratings given to each type of mental health service. We found a correlation of 0.93 between services rated requires improvement or inadequate for leadership, and those with the same ratings for safety.

Similarly, we found a correlation of 0.92 between the best led and most safe mental health services – those rated outstanding or good. A score of 1 is a perfect correlation.

While correlation does not prove causation, the high scores show there is a strong relationship between leadership and safety in mental health services.

Our analysis shows that of the three worst rated services overall for safety, two were also among the worst rated for leadership: acute wards for adults of working age and psychiatric intensive care units; and wards for older people with mental health problems.

Learning disability services topped the list for least well led but was ninth worst for safety (see tables below).

The worst mental health services for safety and leadership, according to CQC ratings

Service/population group	% rated requires improvement or inadequate for safety		Service/population group	% rated requires improvement or inadequate for well led
Acute wards for adults of working age and psychiatric intensive care units	72		Learning disability services/services for people with learning disabilities or autism (combined)	67
Wards for older people with mental health problems	50		Acute wards for adults of working age and psychiatric intensive care units	37
Community based mental health services for adults/adults of working age (combined)	49		Wards for older people with mental health problems	30
Long stay/rehabilitation mental health wards for working age adults	48		Community based mental health services for adults/adults of working age (combined)	28
Long stay/forensic/secure services/forensic inpatient/secure wards (combined)	42		Wards for people with learning disabilities or autism	26

The best mental health services for safety and leadership, according to CQC ratings

Service/population group	% rated good or outstanding for saffety		Service/population group	% rated good or outstanding for well led
Specialist eating disorders services (only four service providers rated)	100		Community based crisis services/community forensic mental health team (combined; only four service providers rated	100
Specialist psychological therapy services (only two service providers rated)	100		Specialist eating disorders services (only four service providers rated)	100
Community based mental health services for older people	100		Specialist psychological therapy services ( only two service providers rated)	100
Community based crisis services/community forensic mental health team (combined; only four service providers rated	100		Community based mental health services for older people	100
Community mental health services for people with learning disabilities or autism	87		Long stay/forensic/secure services/forensic inpatient/ secure wards (combined)	91

Adult mental health services in high demand dominated the top five worst rated services for safety and leadership.

Data published by NHS Digital last month shows the number of adults in contact with mental health services increased by 6 per cent in the 12 months prior to March 2016, but the number of adults detained in hospital rose by 49 per cent in the same period. There was also a 13 per cent increase in adults staying in open acute wards over the 12 months.

Acute wards for adults and psychiatric intensive care units across England received the highest proportion of inadequate or requires improvement ratings for safety, with 72 per cent receiving these ratings. The units received the second highest proportion of poor ratings for leadership, with the CQC reporting 37 per cent of providers needed to improve in this area.

Fifty per cent of mental health wards for older people and community based mental health services were rated inadequate or requires improvement for safety. Around 30 per cent of these services were also poorly rated for leadership.

Andy Bell, deputy chief executive of the Centre for Mental Health, said in areas with high staff turnover it is a “big ask [for a senior leader] to take that on”.

He said “there is brilliant leadership” in mental health trusts but people are “working in exacting circumstances” where mental health budgets have been cut and demands are rising.

“We need to make sure that being a leader in a mental health service is as attractive as other leadership roles and it is given the status is deserves,” he said. It was “inevitable that it is more difficult to maintain quality and safety where you don’t have consistent staffing”, he added.

Jonathan Warren, chief nurse at East London Foundation Trust, one of only two mental health trusts in England to be rated outstanding by the CQC, said the “root cause” behind some mental health services underperforming was “people are really struggling to manage demand”.

He said when services are under pressure, nurses can feel they are “always working to find beds and that is not very rewarding, there are more rewarding parts [of the mental health sector] to work in”. He added: “There is a constant battle to ensure that there are sufficient permanent staff available for wards and adult community mental health teams.”

Mr Warren said it is a “reasonable assumption to make” that services rated good and outstanding for safety and leadership are those where “staff are more able to focus on the direct care of patients”.

However, he pointed out that the four mental health trusts rated outstanding and good overall, including East London, each have “systematic, formal quality improvement programmes [that] trust and empower staff to drive improvement”.

He said: “It is really difficult to do high quality work when you have 30 per cent vacancies, for example – but what comes first? Does empowered staff lead to better recruitment and lower turnover? I would say that has a part to play in the whole safe domain. Our job is to create an environment in which people can thrive and be open with us. We are absolutely relying on our staff to tell us where ligature concerns are, for example.”

Simon Gilby, chief executive of Coventry and Warwickshire Partnership Trust, which is rated requires improvement, said after visiting the outstanding mental health trusts, his organisation can “learn lessons” from their improvement programmes.

“What we saw is that it is very much about a well embedded culture to ensure it is an open organisation and staff feel able to influence [the work they do],” he said.

However, he agreed with some of the systemic concerns raised by others in the mental health sector. Mr Gilby said the needs of mental health inpatients “mean you need the right number of appropriately qualified staff, which is an ongoing challenge quite frankly”. He said the trust is doing “very well” in some services such as street triage as the “nature of these services is that they are vibrant and attract the right people”.

Mr Gilby said if commissioners made more money available to the trust “the first thing I would do is have as many permanent staff as possible, the second would be, in the right areas, to employ more staff”.

HSJ analysed all providers of mental health services, both NHS and independent, that were registered and rated by the CQC at the end of May. There were 22 different types of mental health services rated by the regulator.

For our analysis, HSJ combined a few services where the type of care registered was very similar, such as “community based mental health services for adults” and “community based mental health services for adults of working age”.