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Long read

Mental health 360: quality and patient experience

Overview

  • The proportion of mental health services rated ‘good’ or ‘outstanding’ deteriorated between 2022 and 2023.  

  • There is substantial and unwarranted variation in the quality of care between providers and services.  

  • Satisfaction among NHS mental health care staff with the care their organisation provides has fallen to its lowest level in five years.  

  • The experience of people accessing support for mental illness has declined. 

  • An underlying feature of many identified failings in quality of care is the poor use of, and adherence to, processes that support management of quality and safety. 

The overall quality of care has deteriorated  

Quality of care is the function of a number of objective measures, as well as the experience of staff and patients. The independent regulator, the Care Quality Commission (CQC), uses five domains to assess quality of care: how safe a service is; how responsive a service is; its effectiveness; how caring staff are; and the overall leadership of the service and provider. In recent years, the CQC has moved to a risk-based reinspection regime, increasing the likelihood of identifying poor practice and potential downgrading of services, but changes in score remain a useful indicator of care quality. 

Overall, the CQC rated 74% of all mental health services (NHS and independent) as ‘good’ or ‘outstanding’ in 2023, compared to 77% in 2022. The safety of services continues to be an area of concern, with 40% of providers rated as ‘requires improvement’ or ‘inadequate’ for safety.  

The proportion of services rated 'outstanding' or 'good' has deteriorated between 2022 and 2023

In January 2023, the government announced a rapid review into patient safety in mental health inpatient settings in England. Based on CQC ratings for ‘acute wards for adults of working age and psychiatric intensive care units’ in March 2023, 77% of the NHS trusts and 59% of the independent sector locations were rated ‘requires improvement’ or ‘inadequate’ for safety. 

Staff are concerned about the quality of care they can provide 

In the 2022 NHS Staff Survey, the proportion of staff in NHS providers of mental health care who reported that they would be happy with the standard of care their organisation provided if a friend or family member needed treatment fell to its lowest level in five years (62.8% – reflecting the broader NHS trend). This was despite 78% of staff reporting that the care of patients and service users is their organisation’s top priority.  

A survey of its members by the Royal College of Psychiatrists in March 2022 found that 49% of respondents felt that the quality of mental health care in their area had got worse or much worse in the previous quarter, compared to just 5% who felt that care had improved.  

People accessing support report a worsening experience  

Based on the annual Community mental health survey in 2022, the CQC concluded that people’s experiences of mental health services provided in the community remain poor. Findings include the following:  

  • 29% of respondents reported a good overall experience, down from 32% in 2014 when data was first collected 

  • 40% of respondents felt they had ‘definitely’ seen services enough to meet their needs in the past 12 months, down from 47% in 2014  

  • 55% felt there was definitely enough time to discuss their needs, down from 65% in 2014.  

The survey includes a trend analysis of key questions related to access to care, communication about the care people were receiving, knowing who to contact in a crisis, support for physical health and wellbeing, and management of medicines. All these areas show a significant deterioration in the quality of care between 2018 and 2022.  

A Healthwatch review of feedback received during 2021/22 about adult mental health services highlighted variation in GP support and referrals, long waiting times, oversubscribed crisis services, perfunctory assessments, and inadequate follow-up support.  

Poor processes to identify and learn from issues underlie many failings in quality  

Our analysis of CQC inspection reports as part of this work identified a number of common factors in relation to quality of care. These included specific issues within inpatient services around sexual safety, use of restrictions and restraint, and use of long-term segregation to restrict patients’ interactions with others on the ward, in addition to long waiting times within community services.  

A further set of factors relate to provision of care. Examples include patients on wards being unable to access activities or resources that would support their recovery, or amenities such as facilities for washing clothes and making drinks and food. Lack of staffing was a common factor, as it was often the case that staff were required to facilitate or supervise access.  

Two other factors were identified. The first was a lack of person-centred or personalised care such that the care provided failed to recognise or meet people’s needs (for example, generic care plans). The second was around the culture of care, including a lack of dignity and respect for patients, or behaviour that was uncaring, discriminatory or abusive.  

An underlying feature of these issues was a failure to use or follow processes that relate to quality and safety. These included processes to manage or reduce risk, reporting issues associated with unsafe care, and processes for reviewing care. The ability to make meaningful changes was further compromised by a lack of mechanisms for sharing information or learning from incidents, lack of action planning to implement improvement, or simply lack of action.  

In practice, this means that services were not able to effectively respond to incidents and make appropriate and timely changes to prevent future risk:  

'…we [CQC] reviewed a care record that detailed a patient alleging to staff that they had been sexually abused by another patient three days prior to our inspection. This had not been logged as an incident, reviewed by staff or referred to safeguarding. Managers told us this would be used as an example of learning and would be included in future training; however, a quarter of staff were not allocated to complete the training for up to six months and managers had not taken any immediate action to share learning across the service.'

CQC inspection report

Among these services, a range of approaches were being employed to improve care, including clinical audits, quality improvement methods, and involvement in national accreditation programmes and external research projects. However, even where services were engaged with these activities, associated improvements in care were not always evident.