Better access to safe places in health-based settings for people experiencing a mental health crisis is crucial, urges CQC

22 Oct 2014 02:48 PM

The Care Quality Commission has called for urgent action to continue to improve access to and the operation of health-based places of safety for people experiencing a mental health crisis.

CQC has found that too many health-based places of safety are turning people away because they are already full, and some are refusing to help people who are intoxicated or exhibiting disturbed behaviour.

The regulator has issued a series of recommendations aimed at providers and commissioners yesterday alongside the findings from a survey of all NHS mental health trusts in England and two social enterprises providing health-based places of safety.

People detained by the police under section 136 of the Mental Health Act must be taken immediately to a safe place where a mental health assessment can be undertaken. This should be a ‘health-based place of safety’, located in a mental health hospital or an emergency department at a general hospital. They should only be taken to a police station in exceptional circumstances.

Overall, CQC’s findings suggest that while some health-based places of safety are effective, others are less responsive to people’s needs and require far reaching improvements.

CQC’s key findings are:

• Too many health-based places of safety are turning people away or requiring them to wait for a long time with the police because they are already full or because there are staffing problems. A quarter of providers told CQC that they did not believe that the provision of health-based places of safety in their locality was sufficient.
• Too many providers are operating restrictions which exclude some people from specific groups from accessing a health-based place of safety. This includes young people, people who are intoxicated, and people exhibiting disturbed behaviour.
• Too many commissioners are not adequately fulfilling their oversight responsibilities in relation to people who are detained under section 136. This limits their awareness of a key issue which should inform their commissioning decisions.
• Too many providers are failing to monitor their service effectively, making it difficult to assess whether provision of health-based places of safety is meeting the needs of their localities. Many health based places of safety were unable to provide CQC with basic data about the use of their service or how often people were turned away or excluded.

Dr Paul Lelliott, CQC’s Deputy Chief Inspector of Hospitals (lead for mental health), said: "Since we carried out this survey earlier this year, we know that a great deal of work has been done nationally and locally to improve services for people who experience a mental health crisis and good progress is being made – but findings from our survey and recent inspections of mental health services show clearly that there is still more to do to improve health-based places of safety.

"There is a range of services that can respond to people experiencing a mental health crisis, as well as services that can intervene early to prevent a crisis from happening in the first place. However, if a crisis does escalate and the police do need to use section 136, people should be taken to a place of safety in a healthcare setting.

"What our survey of health-based places of safety found is not good enough. There would be a national outcry if people experiencing a physical health crisis were treated in the same way. Imagine if people who had had a heart attack or stroke, were regularly turned away from an A&E department due to a lack of staff or beds, or if people who had been seriously injured in an accident or attacked were told they couldn’t receive care because they had been drinking or were showing signs of being disturbed.

"We have found that people experiencing a mental health crisis are far more likely to end up in a police cell if a health-based place of safety is not available due to staffing or capacity problems, or has restrictions on access in place. Police are left with no option but to take a person to the police station, which is unacceptable and likely to cause additional distress to an individual who is already in a vulnerable situation.

"To give praise where it is due, we did find a number of providers with appropriate provision who were able to deliver a good service. We hope that those providers and their commissioners who were restricting access or not delivering as good a service will learn from those that are giving people the support that they need.

"The issues we have identified around access to health-based places of safety show why it is so important that parity of esteem is achieved between physical and mental health. We urge providers and commissioners of services and others to pay close attention to our findings and act on our recommendations. This will help them to fulfil their responsibilities under the Mental Health Crisis Care Concordat, but – more importantly – will help those experiencing a crisis to get the support they need, whenever and wherever they need it.

"The Concordat has encouraged many organisations to consider what more they can do in this area, both individually and by working with other agencies, and we are delighted to be a part of this."

Lord Victor Adebowale CBE, Chief Executive of Turning Point and Chair of the Independent Commission on Mental Health and Policing said: "This report reiterates how essential it is that we immediately improve the provision, availability and awareness of health-based places of safety so that people experiencing a mental health crisis can access support wherever they are in the country, without the use of police cells.

"Given the correlation between psychosis and substance misuse, this support should not be dependent on whether someone is intoxicated or demonstrating disturbed behaviour, or subject to delays because beds are not available. Additional care providers should be utilised to ensure there is a range of adequate places of safety available in any local area, for anyone requiring support.

"The most pressing issue, however, is staff training and ensuring that all police officers and health professionals know their role within an effective crisis care pathway that saves people’s lives.” CQC has made a number of recommendations based on its findings, including that:

• Providers should identify areas in which national standards are not being met, working with local partners to address these shortfalls. This includes making sure appropriate arrangements are in place for young people, people who are intoxicated, or people exhibiting disturbed behaviour.
• Providers should improve data collection on how health based places of safety are used.
• Providers should ensure that appropriate levels of adequately trained staff are available to receive an individual brought to the place of safety at all times.
• Commissioners should establish whether local capacity is sufficient, and take action to drive improvements by the commissioning of services or specifying interventions that may prevent or reduce the use of section 136.
• Commissioners should ensure they are fulfilling their responsibilities around multi-agency groups and policies relating to health-based places of safety.
• Commissioners should ensure that ambulance arrangements for transporting people experiencing a crisis are appropriate and timely.
• Health and wellbeing boards should assess local need for health-based places of safety as part of their Joint Strategic Needs Assessments.
• Multi-agency groups should develop and monitor an action plan to address any shortfalls identified, including agreeing alternative arrangements when the place of safety is occupied, and auditing local intelligence on the operation of places of safety, promoting improvements in data quality where required.
• Organisations responsible for the availability of professionals to carry out MHA assessments should take action to minimise delays.
• NHS England should consider the use of capacity management systems to include real-time information on the availability of health-based places of safety, in order to help streamline the process for police and ambulances to access a place of safety.

Read the full report

Norman Lamb, Minister of State for Care, said: "It’s essential that people in crisis get urgent, compassionate care. That’s why I launched the Crisis Care Concordat and I’m grateful to the CQC for its valuable work to help drive up standards.

"We are seeing a reduction in the use of police cells as places of safety across the country but there is still work to do. I urge every area to sign a crisis care declaration by the end of the year because everyone, no matter their age, postcode or circumstances, should get high quality care when they need it."

Home Secretary Theresa May said: "This report is a reminder of the need to improve health-based places of safety in England and Wales. Too many people detained by the police under the Mental Health Act end up in police cells instead of in proper healthcare. This wastes police time and leaves those with mental health problems without the care and support they need.

"We must never accept a situation when a person in crisis is denied care because a health-based place of safety is full or unstaffed, or just because the person is intoxicated. This kind of exclusion is not consistent with the Crisis Care Concordat we launched with the Department of Health in February this year.

"The Home Office and Department of Health are already conducting a review into the use of police powers under the Mental Health Act, which will report shortly, and tomorrow I will host a joint summit with Black Mental Health UK on policing and vulnerable people. I call upon local health leaders, commissioners and providers to build on these efforts and use the CQC’s findings as a prompt to improve care for those that need it."

CQC has updated its map of health based places of safety – first published earlier this year - alongside the report. This map gives details of opening times, areas served, capacity, and the age groups accepted. It can be used by the police to identify the nearest health-based place of safety where a suitable one is available, and also for local providers and commissioners to plan provision.

View our Map of health-based places of safety

The survey and map were both part of CQC’s commitments under the Mental Health Crisis Care Concordat. It is also a key part of a wider themed review which CQC is undertaking on the care and support that people experience during a mental health crisis. A full report on the wider review will publish next year.

Notes to editors

The map showing the location of health-based places of safety in England can be found atwww.cqc.org.uk/hbposmap.

In January and February 2014, CQC collected information via an online survey from 56 mental health trusts and two community interest companies – responsible for the health-based places of safety in local areas throughout England. We requested details on their location, opening times, capacity and usage, any exclusion criteria, staffing and training, multi-agency working, and the support received from the police. We received a 100% response rate from the organisations we surveyed.

There are 58 NHS mental health trusts in total. We did not survey the Tavistock and Portman NHS Foundation Trust, or Calderstones Partnership NHS Foundation Trust, as neither provides a health-based place of safety. The former does not provide mental health inpatient services, and the latter provides services for people with learning disabilities only.

In the financial year 2012/13, there were 21,814 reported uses of Section 136, of which 7,761 involved the use of a police cell. CQC’s work with HM Inspectorate of Constabulary, HM Inspectorate of Prisons and Healthcare Inspectorate Wales in May and June 2012 found that some of the most common reasons for the use of police custody related to the lack of staff or beds available in health-based places of safety.

The Mental Health Crisis Care Concordat is a national agreement between services and agencies involved in the care and support of people in crisis. It sets out how organisations will work together better to make sure that people get the help they need when they are having a mental health crisis.

In February 2014, 22 national bodies involved in health, policing, social care, housing, local government and the third sector came together and signed the Crisis Care Concordat. It focuses on four main areas:

• Access to support before crisis point – making sure people with mental health problems can get help 24 hours a day and that when they ask for help, they are taken seriously.
• Urgent and emergency access to crisis care – making sure that a mental health crisis is treated with the same urgency as a physical health emergency.
• Quality of treatment and care when in crisis – making sure that people are treated with dignity and respect, in a therapeutic environment.
• Recovery and staying well – preventing future crises by making sure people are referred to appropriate services.