“People shouldn’t have to reach crisis point before they can access the care and support they need”

Trigger warning — this article discusses suicidal feelings

In 2017, Hannah* was experiencing a mental health crisis.

She agreed with her team that going into hospital was what she needed to keep her safe and to get the right level of treatment.

But, because there was no hospital bed available, she was sent back to her flat where she was living on her own.

“I've ended up waiting for days for a bed at home,” she says.

Finding being in hospital difficult, it was a big deal for Hannah to agree to go in informally. Informally means going into hospital voluntarily rather than being detained under the Mental Health Act.

Being told that no bed was available and sent back home to wait, made the situation even harder for her.

“It was horrible. Obviously, you're acutely unwell and the stress of saying yes, I will go in when you don't really want to and then suddenly having that weight of just waiting.

“Usually they put you under the crisis team and the crisis team visits you every day, but that's half an hour out of a day and the rest of the time is just sitting, waiting for the call to say that there’s a bed and not knowing where that bed will be.”

Since 1988, the number of mental health beds has decreased by 74 per cent. This means it has gotten harder for patients to access inpatient care when they need it.

The reduction of mental illness beds largely resulted from a policy shift to providing care for people with mental health problems in the community rather than in institutional settings.

Since the late 1950s, there has been a move away from hospitalising people with mental health problems. Instead, it has been sought to provide care through multidisciplinary teams based in the community while people live in their own homes.

This led to closures of inpatient mental health beds in the mid- to late-1980s.

Operating on high bed occupancy rates

A survey from the Royal College of Psychiatrists has found that mental health hospitals in England were operating at capacity in December 2020.

To maintain patient safety standards, bed occupancy should not exceed 85 per cent. A higher bed occupancy leads to regular bed shortages. These are impacting patient care as directing patients to the bed most suitable for their care is less likely to be possible.

Psychiatrists who took part in the survey said there was more pressure on beds compared to the same time the year before. The vast majority estimated there were less than five per cent of beds available in their trust.

As a result, psychiatrists said that they would look to find a bed for patients outside of their local area or delay admission and treat them in the community.

Data obtained through Freedom of Information requests reveals that the majority of mental health trusts that supplied data were operating at bed occupancy rates over 85 per cent.

A spokesperson from the Royal College of Psychiatrists recognises: "Parts of England are dealing with a dangerously high pressure on beds resulting in poor patient and carer experience." Besides the declining trend in bed numbers, the College names capacity in crisis teams and community mental health services as significant contributors to bed pressures.

"Patients should get the right care when and where they need it, that can only be sustainably delivered on the firm foundation of excellent community mental health and social services."

Consequently, the College says that there is a need for additional funding for adequately staffed and resourced specialist mental health beds in priority areas to relieve the current unsustainable pressure they are facing.

Asked about bed pressures, NHS England and NHS Improvement said: "We recognise that NHS mental health bed pressures are extremely high and have been heightened as a result of the pandemic."

Being in year three of the NHS Longterm investment plan for mental health, £1.7bn is being invested in NHS mental health services this year, plus an additional £500m for Covid pressures.

"This investment in the continued expansion of community mental health services, crisis care services and support for people to be discharged from hospital in a timely manner should help to reduce pressures on local inpatient services so that those who need to access beds can do so quickly and locally."

Beds are increasingly allocated based on patients' risks

Every mental health trust has a bed manager who knows how many people are being assessed and waiting to come in.

“They will rate the risk of people and they will prioritise the beds to those that they consider being the most at risk to themselves or others,” says Approved Mental Health Professional (AMHP) Tahir who does not want his real name to be known because of his professional responsibilities.

AMHPs are trained to use the Mental Health Act. They carry out assessments and help decide if someone should be detained.

“If someone is considered riskier, they are more likely to get a bed quicker,” is also what Helen Rees is experiencing. She is a mental health nurse working with 0 to 25-year-olds in the community.

For her, the lack of beds means that it has gotten harder for informal patients to access inpatient support when they need it. She says: “The service that we are offering is increasingly becoming risk-based management.”

“You could be highly distressed and suffering and have an illness that is impacting your life and health outcomes but unless there are significant risks and that kind of threshold is met, getting an inpatient bed is really difficult.”

As a result, people are being left without inpatient support for longer, Helen says — until they get into the position where those risks are there.

“We are having to nurse people to a point in the community where if they got that level of help earlier then they wouldn't get to that riskier stage. But we are having to let people get to that riskier stage because we just can't access inpatient beds in the way we would like to.”

The Care Quality Commission has heard similar reports from trusts:

“We were told that delays in admission due to a bed not being available may mean that a patient, who might have consented to be admitted informally at an earlier stage, may deteriorate and become unwilling or unable to agree to an admission, and therefore need to be detained under the MHA.”

How a lack of beds impacts admissions

With the lack of beds and the difficulties accessing inpatient care, those who are in hospital at the moment are considerably unwell. Tahir says: “The acuity of people on wards is severe at the moment – it means that everybody is unwell, disturbed or distressed.”

This is impacting all patients on the ward. Tahir draws up two scenarios. One where 50 per cent of patients on the ward are detained and 50 per cent are there voluntarily. He would imagine the latter to be less unwell and less distressed. In the other scenario, 85 per cent of people on the wards are detained and severely unwell.

“That’s a very difficult place for other people to be and live in. You might have people very distressed, showing positive symptoms of mental disorder, responding to voices, and being actively suicidal. Staff might have to intervene and do restraints and forced medication. You wouldn’t describe that as a therapeutic environment.”

In 2011, a report by the charity MIND has found that 39 per cent of people in hospital were detained under the Mental Health Act.

Back in 2011, NHS Digital said in their Mental Health Bulletin: “This suggests that NHS psychiatric hospitals are increasingly used to care for and contain people who are seriously mentally ill and who are considered to pose a risk to themselves or others.”

Ten years later, the ratio of detained patients in wards is considerably higher.

The Royal College of Psychiatrists is concerned by the rising numbers of formal admissions. A spokesperson says:

“Patients must get care appropriate to their needs and informal treatment and support is preferable over compulsory powers which should only be exercised as a last resort.

“However, the high level of formal admissions is in part caused by a lack of services, leading to patients receiving care too late, once in a point of crisis.”

Though the College stresses the preference for informal admission and that compulsion should always be a last resort, in many cases detention is necessary and provides patients with the care they need and with more safeguards in place.

The College wants to see expanding service provision and accessibility while tackling societal injustices and ingrained inequalities to solve these issues.

Lucy Schonegevel, Associate Director for Policy and Practice at Rethink Mental Illness said: “People shouldn’t have to reach crisis point before they can access the care and support that they need.”

According to her, the transformation of community mental health services set out in the NHS Long Term Plan, supported by the long overdue reform of the Mental Health Act, both have the potential to help reduce the number of people in inpatient care.

“However, this potential progress is juxtaposed with local authorities making significant cutbacks to mental health social care over the same period. We urgently need a solution to the crisis facing social care. Until social care funding and resources are in place to support people to live independently and prevent them from reaching crisis, pressure on NHS inpatient services will continue to grow.”

Responding to this, NHS England and NHS Improvement said that all areas are working to deliver 24/7 adult community-based crisis and home treatment teams, alongside a five-year ringfenced investment in ‘crisis alternatives’ to A&E and admission.

“It is worth noting that in some places where they are meeting more needs in the community, they might only need inpatient care for the most unwell people and therefore a higher percentage of people who are cared for on wards would be detained under the Mental Health Act.”

Trusts with high rates of detained patients

In 2018, the Care Quality Commission published a report on the rise in the use of the Mental Health Act to detain people in England.

They found that some NHS wards would only admit people if they were subject to the Act. With bed occupancy exceeding 100 per cent in some areas, even patients requiring an admission under Section 2 might experience delays.

The data obtained through Freedom of Information shows that in some trusts the ratio of detained to informal patients on the wards is higher than in others.

What the lack of beds means for detentions

A lack of beds does not only impact informal admissions.

If there is no bed available, then a patient cannot be detained, Tahir says.

“The tricky thing is the AMHP can’t make the application to detain a patient until the NHS tells the AMHP where the bed is,” Tahir says.

“If there is no bed, they are not detained. No one is detained until the AMHP makes the application.

“This means the person is free to go about their business. And that’s a real problem sometimes.”

For example, if Tahir assesses someone in their home but cannot detain them because of a lack of beds, he has to come back later and ask them to let him back in. He has no power of entry.

“Just imagine getting the Mental Health Act sorted and then having to explain to people that you intend to detain them, but that you can’t and that they will need to wait. That they will need to keep themselves safe and manage any risks until then.

“It doesn’t feel good, it doesn’t feel ideal. I always describe the system as being dysfunctional and difficult to navigate.”

When Hannah was detained under Section 2 of the Mental Health Act last year, there was, again, no bed available for her.

Therefore, she was put in a Section 136 suite — usually used for people detained by the police under Section 136 of the Mental Health Act. It is supposed to provide a place of safety while assessments are carried out.

“There were no beds, so they had to put me in a 136 which is like a cell. It’s just got a plastic bed and they took all my clothes off me and put me in ligature proof clothes, and there was a little camera in the corner. It was horrible.”

Hannah had to stay in the suite for 24 hours until a bed was found.

Restrictions to community care

When no bed is available for patients and they cannot be detained or admitted informally, the responsibility falls to the community teams to care for the patients.

From Helen’s experience, the team would work closely with an individual to produce a suitable care package.

That could be that home treatment or crisis teams go in regularly. It could also be helping someone access talking therapies.

“I think the most important thing we would do is provide that therapeutic relationship, that acknowledgement that we are there for that individual, that unconditional positive regard as well as advocating for them and pushing for the access to the services they need.”

However, Helen is experiencing restrictions on what she can do on a community basis. This is mainly due to an increased demand for community services with referrals going up.

“The referrals are so overwhelming at the moment,” Helen says and adds:

“I'm probably telling ideal world scenarios. Whether people would actually get that in reality would depend on how busy the particular service was where they lived.”

The number of referrals to mental health services have hit their highest point in two years. The latest figures by NHS Digital show that between March and May 2021, over one million new referrals were made to mental health services.

Hannah knows what stretched community services and struggling to get the right support feel like:

“It’s hard to get help initially and then it’s hard to keep that help. Everything is time-limited, and you sort of move from service to service. There is definitely not enough support in the community at all.”

"I was let down by services"

Lockdowns, restrictions, and not being able to meet friends. The pandemic has had a big impact on Pavan's mental health. Added to that, he lost someone he knew to suicide in early 2020. When Pavan felt himself getting low, he reached out to his mental health team — but no additional support was put in place.

“They felt that I wasn’t at too much of a risk,” Pavan says.

Over weeks, his mental health deteriorated further. In the span of three weeks, he attempted suicide twice. Still, he did not get any extra support from mental health services, he says.

“Despite that distressing episode I had in June 2020, however bad it was, there was just nothing out there for me.”

After his second attempt, he got taken to the hospital.

“This time, it escalated straight to the police getting involved. I was taken to a general hospital and kept there on 1:1 monitoring because of concerns for my welfare.”

After one week, Pavan got discharged, feeling slightly better, he says. Today, he is not feeling suicidal or in crisis. But he is still waiting for help from services: "I continued living with minimal to no support."

He would have wanted regular sessions with the mental health team.

“Barely anything was put in. I was quite let down. I don’t think I would have gotten to the point of getting hospitalised if I was given the right support.”

Trusts not operating admission waiting lists

While there are waiting lists for talking therapies, the majority of mental health trusts do not operate a waiting list for admissions. Out of 37 trusts that replied to an FOI about this matter, only eight trusts (22 per cent) are operating a waiting list. At the end of June 2021, 351 patients in these trusts were waiting for a bed.

The longest time a patient on the lists has been waiting for an admission was 288 days in Birmingham and Solihull Mental Health NHS Foundation Trust. On average, patients in that trust have been waiting 28 days for a bed.

In Mersey Care NHS Foundation Trust, one patient has already been waiting for 272 days — 2.5 times the average waiting time of 111 days.

Both trusts were approached for comment but have not responded.

The shortest waiting times have been recorded in Camden and Islington NHS Foundation Trust where patients have been waiting on average three hours until they got admitted.

Trusts that were not able to report on this data often said that a bed will be found when a person needs to be admitted — and therefore no waiting list is required. Berkshire Healthcare NHS Foundation Trust referred to their Crisis Response Home Treatment Teams that can support patients in the community.

Trusts admitted that “patients will occasionally be placed out of area if no bed is available locally”.

This is despite the national ambition of eliminating inappropriate Out of Area Placements by the end of March 2021 — a deadline that has passed by now.

Despite this, 440 patients were newly placed out of their area in May 2021 because no local beds were available.

More beds, more staff, more early intervention

When Helen talks about her role, she describes reducing coercion and restriction and co-producing care as key parts. Not being able to provide the right support at the right time leads to a risk of moral injury, she says.

“I think that because we can't get beds when people are willing to go into hospital informally, there's a real risk of moral injury there because we can't support people in the way that we would like to — which would be in a least coercive, informal way.”

Moral injury leads in part to a high turnover of staff which affects the delivered care.

Therefore, Helen would like to see community services that are commissioned and designed by nurses and people with lived experience.

“I think you need to ask the people that deliver the care, which is the nurses, and the people who receive the care and design some really high quality, well-staffed, well-funded community services that are what people need.”

By that, Helen specifies, she does not mean home treatment and crisis teams, but services that support patients before they get into a period of distress.

To reduce restrictive care, Helen says more beds in the NHS are needed.

“Trusts need to have a responsibility not to place people out of area and to do that, they need to access beds. And I'm completely committed to people receiving care in the community. That is what we would all want and that's what patients want when it's safe to do so.

“But we can't avoid the fact that not everybody can stay well through community services alone. Some people are going to need inpatient care in order to stay well and they can't do that unless there are more beds.”

A job that has become more challenging

Tahir has been working as an AMHP for over 20 years. When he started his job, there were more beds and more provision.

He has met and assessed thousands of people, walking alongside them on a tiny bit of their journey through life.

“It’s a privilege to be invited into people’s lives at sometimes the lowest point. Sometimes people like me literally save your life. It doesn’t feel like that, but we actually save people’s lives. And sometimes we fail.”

Over time, the job has become more challenging. “It’s hugely frustrating at times because it feels as if you’re fighting against the system,” Tahir says.

In January this year, the Government released its white paper Reforming the Mental Health Act. This was following an independent review of the Act in England led by Sir Simon Wessely. The Royal College of Psychiatrists sees this as an "welcomed move to implement many of the reforms proposed in the Wessely Review that was primarily aimed at reducing detentions and compulsion in the Act".

Although many of the proposals will provide patients with greater safeguards, the Royal College of Psychiatrists stresses that in order to achieve a reduction in detentions and an improvement in care, the Government needs to provide adequate service provision.

“It must accompany any legislative changes with substantial investment in community mental health and learning disability services, as well as expanding the stretched mental health workforce.”

Tahir was party to the Mental Health Act review. For him, the Act itself isn’t the problem.

“It’s the lack of provision, it’s the lack of early intervention, it’s the lack of tackling the social determinants of health, it’s the lack of beds, it’s the lack of investment — it’s mental health services being underinvested in for decades and decades. It cannot meet the demand that has been placed upon it.”

---

In the UK, the charity Mind is available on 0300 123 3393. You can also call the Samaritans on 116 123, email them at jo@samaritans.org, or visit samaritans.org to find your nearest branch.

More information about hospital admissions and the Mental Health Act can be found here:

• Rethink Mental Illness explains what detention under the Mental Health Act 1983 means.
• Information on your rights as voluntary and detained patients.
• Tipps from Mind on how to find an advocate. An advocate can help you express your views and stand up for your rights.

---

Get the data

Data on the status of patients, admission waiting times and bed occupancy rates has been obtained through Freedom of Information requests. The full replies, data and analysis can be found in this GitHub repository. It also contains the data on individual NHS trusts.

Get in touch

There are many things I couldn’t cover (yet). If you have anything to add, want your story to be told or simply want to talk about the issue, send me an email or message me on Twitter.

---

Never want to miss a story again? Subscribe to my newsletter and get notifications for new stories, interviews and data analysis.