The urgent need to improve care for people with mental ill health John Tingle
T
he Care Quality Commission (CQC), the independent regulator of health and social care in England, has just published a report, Right here, right now (CQC, 2015). The report explores people’s experiences of help, care and support during a mental health crisis. Hard-hitting, it found the quality of mental health care services to be variable and inconsistent across the NHS. The central theme of the report is that the most vulnerable people in society are being abandoned at a time of personal crisis. The failings it identified also have important patient safety implications. The report does identify some areas of good practice, but the overall message is that major improvements in this care area must be made to protect fully the interests of people suffering a mental health crisis.
Context: mental health problems are common Apart from the huge numbers of people in the UK who experience a mental health problem, it is important to note that many healthcare reports, and the attention of health policy makers, tend to focus on physical illnesses, such as cancer. Mental health care has a lesser profile, even though it is extremely common, and is a neglected area within the NHS, existing in an almost Cinderella-like fashion. The Mental Health Foundation (2015) gives some alarming facts about the incidence of mental health problems in the UK: ■■ About one in four of the population will experience some kind of mental health problem in the course of a year, with mixed anxiety and depression the most common. ■■About one in ten children has a mental health problem at any one time. ■■Depression affects one in five older people.
The CQC report
John Tingle is Reader in Health Law, Nottingham Law School, Nottingham Trent University
710
The report was based on a national data review—a call for evidence from people who have experienced a mental health crisis to share their experiences. There was also a survey and a map of health-based places of safety and local area inspections. The CQC call for evidence ran for 6 weeks in spring 2014 and, in total, received 1756 responses. Of these, 985 came from people who had experienced a crisis; 545 were from people who cared for someone during a mental health crisis; and 226 were from groups who told the CQC about crisis care services in their local area.
Personal experiences of crisis care When the responses to the CQC call for evidence were analysed, only 14% of respondents felt that the care they received helped to resolve their crisis, while 84% felt it was not helpful, or only partially helpful. The report goes on: ‘It is very concerning that, for every 10 people who experienced a mental health crisis and responded to our survey, at least eight received a response they felt did not fully meet their needs. This kind of feedback would be unthinkable for physical health emergencies and it should also be seen as unacceptable for people with mental health emergencies’ (CQC, 2015: 21) Analysis of feedback from local groups reinforced the view that local services are struggling to provide high-quality, effective care for people in a crisis. The report states that, in total, 56% of groups said that they felt services in their local area offered ‘poor’ or ‘very poor’ care, while only 18% felt they offered ‘good’ or ‘very good’ care.
Mental health care: not a 9–5 service A key issue identified in the report is access to mental health care services when people need them. People suffering such a crisis cannot plan to have the problem conveniently fit in with the opening hours of care services, 9 am to 5 pm. The times of GP and outpatient services are not always appropriate either. Except for people with dementia, most people with a mental health condition, according to the report, are admitted to hospital via the accident and emergency department (A&E) (i.e. outside 9 am to 5 pm).The peak hours for selfharm admissions are between 11 pm and 5 am, when they account for 6% of all people admitted to A&E. The CQC asked people to tell them about all the different organisations they saw during their crisis event. More people accessed GP services (58% of all responses) than any other service. However, the report also found that 34% of people said that they went to A&E: ‘While we recognise that there will be times when this is entirely appropriate—for example when someone has harmed themselves and needs to be assessed and treated for their physical health needs—the evidence also indicates that people are turning to A&E because they do not feel they can access the help they need elsewhere, or because they have been told to go there by another service.’ (CQC, 2015: 22–3) But the report also states that just over half of those who came into contact with a GP felt they got a timely response:
© 2015 MA Healthcare Ltd
John Tingle discusses the Care Quality Commission (CQC) report on people’s experiences of help, care and support during a mental health crisis
British Journal of Nursing, 2015, Vol 24, No 13
British Journal of Nursing. Downloaded from magonlinelibrary.com by 193.061.135.112 on November 13, 2015. For personal use only. No other uses without permission. . All rights reserved.
PATIENT SAFETY ‘While this is one of the better responses for services providing support in a crisis, it is still concerning because of the implications it may have for the other services in the system. If more than one in three people do not feel they can get help from their GP when they need it, they may choose to use another route, such as accessing support from liaison services based at acute hospitals. Alternatively, they may not access any services until the crisis reaches a point where the police have to intervene.’ (CQC, 2015: 23) Services that are likely to be provided by NHS mental health trusts were perceived as particularly poor for offering a timely service. The most positive response was for telephone helplines—and even they were seen to provide help in a timely way only 50% of the time. Seventy-four percent of respondents felt that access to volunteers and charities was timely.
Patient respect, compassionate treatment? After all the problems at Mid Staffordshire and elsewhere, and the reports that followed, a compassionate and patient-centric NHS should now be the norm. Also, a major reason for health litigation and complaints are failures in communication. If channels of communication with patients could be improved, there would be fewer complaints and legal claims. Patients need to know that they are being listened to and that they will be treated with respect and compassion. This is not always happening, according to the report, when people suffering a mental health crisis are being treated in A&E. A&E was highlighted in the report as the place where most people felt they had been judged (52%, which is 11% higher than for the next service). In addition, people scored it lowest for taking their concerns seriously and treating them with warmth and compassion. People did not feel that A&E was a service that demonstrated empathy.While 34% of respondents said they were treated with warmth and compassion, over half (52%) said they were not: ‘People shared a number of concerning experiences with us, but there does not appear to be one single factor to explain why the experiences of people in crisis in A&E are so poor.’ (CQC, 2015: 26) People’s experiences of specialist mental health services were also varied. Feedback from people who came into contact with the police in a public place during their crisis shows that the police service is seen in a more positive light than many of the specialist health services.
© 2015 MA Healthcare Ltd
Advice and support The report found it particularly concerning that half of all respondents who came into contact with a community-based mental health team felt that the advice and support they received was not right for them, and did not give them ‘the right information’ (CQC, 2015: 31). In particular, participants from minority ethnic communities did not feel that the advice and information available was relevant to people from all backgrounds.
British Journal of Nursing, 2015, Vol 24, No 13
Variation in every direction The report states that for every service that the CQC looked at, they found that the experiences of respondents varied greatly: ‘We heard from people who praised their GP and criticised their mental health team, but we also heard from people who found the support they needed with a specialist team after feeling let down by their doctor.’ (CQC, 2015: 34) The strongest message from the call for evidence, according to the report, is that there is no uniform experience for people needing help, care and support during a crisis. Some people praised their A&E, others did not.
GP support It is estimated, the report states, that one in four patients of a full-time GP will need treatment for mental health problems, and many more of those will come into regular contact with more specialist services. From the research done, the CQC found that the majority of people scored GPs highly, with the most positive responses relating to the GP’s attitude: people felt listened to, treated with compassion, and not judged: ‘While these results are better than those for other health services, it is concerning that around a quarter of patients are not satisfied, and that almost 40% felt the advice and support they were given were not suitable. This suggests there is a substantial minority of people who are not getting the help, care and support they need when they are in crisis.’ (CQC, 2015: 38)
Recommendations According to the CQC, their findings suggest a health and care landscape that is struggling to provide the appropriate levels and quality of responses and support across the system. The report presents the key challenges and opportunities that need to be met, as well as a ‘route map’ for going forward. There is still too much variation across the country, and even within the same local authority areas.
Conclusion The report is very clearly written and is an in-depth analysis of a key area of health care that seems to have become forgotten in some quarters. Mental health care for people in a crisis seems to exist on the fringes of the NHS. Policy makers, commissioning services and other parties concerned with quality at all levels of the NHS need to focus more on this care area, as it is failing conspicuously to meet the care needs of the most vulnerable of people in our community at so many levels. There is good practice identified in the report, but it seems to be eclipsed by the many failings identified. In short, much more can and should be done to improve this BJN important area of health care. Care Quality Commission (2015) Right here, right now: People’s experiences of help, care and support during a mental health crisis. http://tinyurl.com/pl2fr3y (accessed 29 June 2015) Mental Health Foundation (2015) Mental Health Statistics. http://tinyurl. com/4xtrjnv (accessed 2 July 2015)
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British Journal of Nursing. Downloaded from magonlinelibrary.com by 193.061.135.112 on November 13, 2015. For personal use only. No other uses without permission. . All rights reserved.
T
he Care Quality Commission (CQC), the independent regulator of health and social care in England, has just published a report, Right here, right now (CQC, 2015). The report explores people’s experiences of help, care and support during a mental health crisis. Hard-hitting, it found the quality of mental health care services to be variable and inconsistent across the NHS. The central theme of the report is that the most vulnerable people in society are being abandoned at a time of personal crisis. The failings it identified also have important patient safety implications. The report does identify some areas of good practice, but the overall message is that major improvements in this care area must be made to protect fully the interests of people suffering a mental health crisis.
Context: mental health problems are common Apart from the huge numbers of people in the UK who experience a mental health problem, it is important to note that many healthcare reports, and the attention of health policy makers, tend to focus on physical illnesses, such as cancer. Mental health care has a lesser profile, even though it is extremely common, and is a neglected area within the NHS, existing in an almost Cinderella-like fashion. The Mental Health Foundation (2015) gives some alarming facts about the incidence of mental health problems in the UK: ■■ About one in four of the population will experience some kind of mental health problem in the course of a year, with mixed anxiety and depression the most common. ■■About one in ten children has a mental health problem at any one time. ■■Depression affects one in five older people.
The CQC report
John Tingle is Reader in Health Law, Nottingham Law School, Nottingham Trent University
710
The report was based on a national data review—a call for evidence from people who have experienced a mental health crisis to share their experiences. There was also a survey and a map of health-based places of safety and local area inspections. The CQC call for evidence ran for 6 weeks in spring 2014 and, in total, received 1756 responses. Of these, 985 came from people who had experienced a crisis; 545 were from people who cared for someone during a mental health crisis; and 226 were from groups who told the CQC about crisis care services in their local area.
Personal experiences of crisis care When the responses to the CQC call for evidence were analysed, only 14% of respondents felt that the care they received helped to resolve their crisis, while 84% felt it was not helpful, or only partially helpful. The report goes on: ‘It is very concerning that, for every 10 people who experienced a mental health crisis and responded to our survey, at least eight received a response they felt did not fully meet their needs. This kind of feedback would be unthinkable for physical health emergencies and it should also be seen as unacceptable for people with mental health emergencies’ (CQC, 2015: 21) Analysis of feedback from local groups reinforced the view that local services are struggling to provide high-quality, effective care for people in a crisis. The report states that, in total, 56% of groups said that they felt services in their local area offered ‘poor’ or ‘very poor’ care, while only 18% felt they offered ‘good’ or ‘very good’ care.
Mental health care: not a 9–5 service A key issue identified in the report is access to mental health care services when people need them. People suffering such a crisis cannot plan to have the problem conveniently fit in with the opening hours of care services, 9 am to 5 pm. The times of GP and outpatient services are not always appropriate either. Except for people with dementia, most people with a mental health condition, according to the report, are admitted to hospital via the accident and emergency department (A&E) (i.e. outside 9 am to 5 pm).The peak hours for selfharm admissions are between 11 pm and 5 am, when they account for 6% of all people admitted to A&E. The CQC asked people to tell them about all the different organisations they saw during their crisis event. More people accessed GP services (58% of all responses) than any other service. However, the report also found that 34% of people said that they went to A&E: ‘While we recognise that there will be times when this is entirely appropriate—for example when someone has harmed themselves and needs to be assessed and treated for their physical health needs—the evidence also indicates that people are turning to A&E because they do not feel they can access the help they need elsewhere, or because they have been told to go there by another service.’ (CQC, 2015: 22–3) But the report also states that just over half of those who came into contact with a GP felt they got a timely response:
© 2015 MA Healthcare Ltd
John Tingle discusses the Care Quality Commission (CQC) report on people’s experiences of help, care and support during a mental health crisis
British Journal of Nursing, 2015, Vol 24, No 13
British Journal of Nursing. Downloaded from magonlinelibrary.com by 193.061.135.112 on November 13, 2015. For personal use only. No other uses without permission. . All rights reserved.
PATIENT SAFETY ‘While this is one of the better responses for services providing support in a crisis, it is still concerning because of the implications it may have for the other services in the system. If more than one in three people do not feel they can get help from their GP when they need it, they may choose to use another route, such as accessing support from liaison services based at acute hospitals. Alternatively, they may not access any services until the crisis reaches a point where the police have to intervene.’ (CQC, 2015: 23) Services that are likely to be provided by NHS mental health trusts were perceived as particularly poor for offering a timely service. The most positive response was for telephone helplines—and even they were seen to provide help in a timely way only 50% of the time. Seventy-four percent of respondents felt that access to volunteers and charities was timely.
Patient respect, compassionate treatment? After all the problems at Mid Staffordshire and elsewhere, and the reports that followed, a compassionate and patient-centric NHS should now be the norm. Also, a major reason for health litigation and complaints are failures in communication. If channels of communication with patients could be improved, there would be fewer complaints and legal claims. Patients need to know that they are being listened to and that they will be treated with respect and compassion. This is not always happening, according to the report, when people suffering a mental health crisis are being treated in A&E. A&E was highlighted in the report as the place where most people felt they had been judged (52%, which is 11% higher than for the next service). In addition, people scored it lowest for taking their concerns seriously and treating them with warmth and compassion. People did not feel that A&E was a service that demonstrated empathy.While 34% of respondents said they were treated with warmth and compassion, over half (52%) said they were not: ‘People shared a number of concerning experiences with us, but there does not appear to be one single factor to explain why the experiences of people in crisis in A&E are so poor.’ (CQC, 2015: 26) People’s experiences of specialist mental health services were also varied. Feedback from people who came into contact with the police in a public place during their crisis shows that the police service is seen in a more positive light than many of the specialist health services.
© 2015 MA Healthcare Ltd
Advice and support The report found it particularly concerning that half of all respondents who came into contact with a community-based mental health team felt that the advice and support they received was not right for them, and did not give them ‘the right information’ (CQC, 2015: 31). In particular, participants from minority ethnic communities did not feel that the advice and information available was relevant to people from all backgrounds.
British Journal of Nursing, 2015, Vol 24, No 13
Variation in every direction The report states that for every service that the CQC looked at, they found that the experiences of respondents varied greatly: ‘We heard from people who praised their GP and criticised their mental health team, but we also heard from people who found the support they needed with a specialist team after feeling let down by their doctor.’ (CQC, 2015: 34) The strongest message from the call for evidence, according to the report, is that there is no uniform experience for people needing help, care and support during a crisis. Some people praised their A&E, others did not.
GP support It is estimated, the report states, that one in four patients of a full-time GP will need treatment for mental health problems, and many more of those will come into regular contact with more specialist services. From the research done, the CQC found that the majority of people scored GPs highly, with the most positive responses relating to the GP’s attitude: people felt listened to, treated with compassion, and not judged: ‘While these results are better than those for other health services, it is concerning that around a quarter of patients are not satisfied, and that almost 40% felt the advice and support they were given were not suitable. This suggests there is a substantial minority of people who are not getting the help, care and support they need when they are in crisis.’ (CQC, 2015: 38)
Recommendations According to the CQC, their findings suggest a health and care landscape that is struggling to provide the appropriate levels and quality of responses and support across the system. The report presents the key challenges and opportunities that need to be met, as well as a ‘route map’ for going forward. There is still too much variation across the country, and even within the same local authority areas.
Conclusion The report is very clearly written and is an in-depth analysis of a key area of health care that seems to have become forgotten in some quarters. Mental health care for people in a crisis seems to exist on the fringes of the NHS. Policy makers, commissioning services and other parties concerned with quality at all levels of the NHS need to focus more on this care area, as it is failing conspicuously to meet the care needs of the most vulnerable of people in our community at so many levels. There is good practice identified in the report, but it seems to be eclipsed by the many failings identified. In short, much more can and should be done to improve this BJN important area of health care. Care Quality Commission (2015) Right here, right now: People’s experiences of help, care and support during a mental health crisis. http://tinyurl.com/pl2fr3y (accessed 29 June 2015) Mental Health Foundation (2015) Mental Health Statistics. http://tinyurl. com/4xtrjnv (accessed 2 July 2015)
711
British Journal of Nursing. Downloaded from magonlinelibrary.com by 193.061.135.112 on November 13, 2015. For personal use only. No other uses without permission. . All rights reserved.
