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Long read

Mental health 360: acute mental health care for adults

Overview

  • Use of the Mental Health Act has increased. Many more people are getting to a state of crisis where detention is necessary rather than being able to receive support earlier.  

  • There are an increasing number of people in hospital, fewer beds, and increases in length of stay. This places pressure on providing timely access to inpatient care for those who need it.  

  • There is a lack of progress nationally on reducing the number of people inappropriately placed in hospitals out of area, despite a commitment to eliminate this practice by 2021. 

  • There are concerns over quality of inpatient care, with the number of restrictive interventions increasing. 

People are not getting help early enough to prevent detention 

Despite national aims to intervene early, many people are getting to a state of crisis in which detention is necessary. Between 2005/6 and 2015/16, there was a 40% increase in the reported number of times the Mental Health Act was used. In 2016, the means for collecting data changed; however, the trend of rising rates of detention has continued. Since 2016/17, there has also been a 45% increase in the number of people detained by the police and removed to a place of safety under section 136 of the Mental Health Act.  

The number of people in hospital has increased 

Between April 2016 and November 2023, there was a 24% increase in the number of people in hospital, although since April 2021 the number has remained relatively steady. The latest NHS Benchmarking survey of mental health providers found that the average length of stay in an adult acute mental health bed had increased (from 32 days in 2014 to 39 days in 2023). National data also shows that the number of patients with a stay of more than 60 days increased by 22% between June 2021 and November 2023. This places increased pressure on available beds, and may indicate either missed opportunities to provide effective support earlier in the care pathway or delays in access to appropriate support post-discharge.  

The total number of mental health beds is at an all-time low 

With the exception of the Covid-19 period, when many beds were closed due to infection control, the current numbers of mental health beds (17,836) are at their lowest level since data collection began in 2010/11. Bed occupancy has remained consistently over the recommended level of 85%  the point at which quality of care is at risk of being compromised. As a consequence, people who need to be admitted can face considerable delays in accident and emergency (A&E) while they wait for an available bed, or may be cared for in inappropriate environments, such as being admitted to a ward in an acute trust.  

The number of mental health beds has declined, despite bed occupancy remaining above recommended levels

There has been limited progress on reducing inappropriate out-of-area placements 

Inappropriate out-of-area placements – when patients are sent out of area because no bed is available for them locally – can delay the patient’s recovery and are associated with increased risk of suicide. In 2016, the government set a national ambition to eliminate such placements in mental health services for adults in acute inpatient care by March 2021. However, there has been limited progress to date in reducing the numbers.  

The number of inappropriate out-of-area placements has not declined over time

In October 2023, of those people in out-of-area placements, 59% had to travel 100km or more from their home. An analysis of acute mental health care pathways found no correlation between local bed numbers and use of out-of-area placements. This means that out-of-area bed use is unlikely to be due simply to a lack of beds but instead relates to flow issues across the whole system. These include available community capacity and the provision of appropriate alternatives to admission, both of which can reduce the demand for local beds. 

More patients have been subject to restrictive practices 

The Mental Health Act requires care to be provided in the least restrictive way. In 2017, the Care Quality Commission (CQC) highlighted concerns around overly restrictive care among mental health providers, including the use of physical restraint, rapid tranquilisation and seclusion. Restrictive interventions are often a major contribution to delaying a patient’s recovery. They have also been linked with causing serious trauma (physical and psychological), both for the people who use services and the staff providing those services.  

'Three people had been injured during restraints at [XXX] Hospital and 32 incidents of injury were reported for health care assistants with some requiring treatment.' 

CQC inspection report  

NHS England commissioned a national Mental Health Safety Improvement Programme that aimed to reduce the incidence of restrictive practice in inpatient mental health and learning disability services by 50% by March 2024. However, between September 2020 (when data was first collected) and October 2023, the recorded number of restrictive practices increased by over 70%, and the number of people subject to them increased by nearly 40%. These changes may be affected by actual increases in the use of restrictive practices as well as improvements in reporting.