NHS reliant on beds in the independent sector for mental health care

Nationally, there has been a long-term focus in mental health policy on moving care out of hospitals and into the community – from deinstitutionalisation to the recent community mental health transformation programme within the NHS Long Term Plan. However, a series of failures in care mean the spotlight is once again on mental health inpatient services, and with it arises the question of how the need for timely and effective care is best met and by whom.

Current policy and trends in acute mental health care

There has been ongoing concern about the capacity and quality of mental health inpatient care for a number of years. In 2016, a national commission found that access to inpatient beds was inadequate but that bed shortages were symptomatic of broader challenges across the sector, including capacity and resourcing of community-based care. Subsequent analysis highlighted a small number of geographical areas where there was a strong argument for additional investment in beds, while identifying a need more generally for local systems to review the purpose of inpatient admissions and assess service capacity.

Nationally, there has been a focus on expanding access to community-based care and alternatives to hospital admission, in parallel with a drive to reduce length of stay for people who are admitted to hospital. This aims to ensure that people receive access to treatment in the least restrictive setting and to maximise inpatient capacity. Despite this, NHS bed occupancy has remained consistently above the recommended level of 85%, indicating a high level of pressure across the acute care pathway and posing a risk to safety and effectiveness of care. Concerns have been raised around people being discharged too early without sufficient support, leading to readmission. Furthermore, a commitment to eliminate inappropriate out-of-area placements has been missed over many years. As a survey of psychiatrists concluded: mental health beds are full.

Understanding the role of the independent sector

There has been a longstanding relationship between NHS mental health services and the independent sector, particularly around the provision of specialised services commissioned at a national level. However, in recent years there has been a reported expansion in the independent sector, with an estimated 92% of market value accounted for by public-funded care and driven by high NHS occupancy levels. With no centrally collected and published data on mental health beds in the independent sector, the picture of how care is changing is hidden. To address this gap, The King’s Fund conducted a unique analysis – compiling publicly available data on independent service provision and combining this with current bed capacity in the NHS. In this long read we outline our findings.

The hidden picture of inpatient mental health care

In quarter 4 of 2024/25, NHS trusts reported a total of 17,999 available mental health beds, 89.5% of which were occupied. However, our work found that during the same period there were an additional 7,195 beds available in the independent sector, excluding those explicitly allocated for the care of privately funded patients. This accounts for approximately 28.6% of mental health bed capacity in England.

The independent sector comprises a range of non-NHS providers, including private sector, charities and social enterprises. Among the private providers, 67% of beds are provided by three large organisations. Similarly, the majority of beds provided by charities and social enterprises can be accounted for by three large organisations, of which two are commissioned to provide a range of services for the local community in a similar way to NHS trusts. In total, however, beds provided by charities and social enterprises remain a small proportion of the beds overall.

Scale and scope of inpatient beds

The independent sector provides inpatient care to meet a range of needs. There are some areas of care, particularly those that were historically commissioned at a national level, where the independent sector has played a longstanding role. This includes inpatient treatment for children and young people, and forensic mental health services in the form of low and medium secure units that provide assessment and treatment for people with mental illness whose behaviour has led to involvement in the criminal justice system. As our analysis indicates, this continues to be the case, with 259 beds in the independent sector available for the treatment of children and young people compared with 405 beds that were occupied by children and young people in the NHS during the same period. Similarly, 1,719 beds were available for the provision of forensic mental health care in the independent sector, compared with 3,685 occupied for the same purpose in the NHS.

For other areas of care, which traditionally have been commissioned at a local level, the expectation is that capacity should be determined by population need. One such area is care for people who need to be admitted in a crisis – either to an adult acute mental health ward or an adult psychiatric intensive care unit (PICU). We found that there were 8,872 beds that were occupied for this purpose in the NHS, with an additional 2,167 beds allocated as providing acute inpatient or PICU care in the independent sector. As a result, between 17% and 20% of available bed capacity was provided by the independent sector. Our research found examples of whole private hospitals that are explicitly allocated for the admission and treatment of NHS patients.

Looking at the breadth of provision, there are particular areas of care that the independent sector specialises in. These include inpatient treatment for people with neurological conditions and acquired brain injury, eating disorders, and people with learning disabilities and autism.

A surprising finding was the number of wards that are specialising in the treatment of people with a diagnosis of a personality disorder. With the exception of secure units, these are almost entirely designated for the treatment of women. There is considerable controversy in the treatment of people with a diagnosis of personality disorder, and in particular the use of inpatient care, while models that have been adopted to manage the care of people who frequently present to services in a crisis in the community have received criticism. The NHS Long Term Plan supported an expansion in services for people with a diagnosis of personality disorder, including access to evidence-based psychological therapies. However, our data indicates that for a significant number of people, often those with the most complex issues, care may increasingly be provided by the independent sector. Although these placements fall outside the definition of inappropriate out of area treatment, concerns have been raised about the oversight and provision of such care.

Capability and flexibility

A key factor influencing capacity is access to capital investment. The mental health estate is some of the oldest in the NHS, with 18% constructed before the NHS was formed and multiple sites classified as ‘not functionally suitable’. The Care Quality Commission’s latest report highlights how poor environments lead to issues around privacy and dignity for patients and compromise the safety of both patients and staff.

Access to capital investment in the NHS has been constrained – disproportionately so for mental health providers. In contrast, the private sector is able to make that investment in response to market need. Furthermore, it is evident that private providers have a level of flexibility that enables them to change provision according to the needs of that market. For example, a comparison of CQC inspection reports and provider websites highlights several examples of providers reconfiguring capacity following enforcement action, notably from providing inpatient care for children and young people to care for working-age adults. Similarly, we identified several examples of where providers are reconfiguring existing capacity with the stated aim of increasing acute care provision.

This flexibility also provides the opportunity to develop a range of options offering differential levels of intervention and supporting greater independence. Examples included sites that provide supported housing and individual units tailored to the needs of specific populations. This was particularly evident in the treatment and care of people with learning disabilities and autism, and rehabilitation care for people with mental illness.

The diversification of NHS-funded mental health care provision

The provision of mental health care by independent sector providers is not new, particularly in relation to the delivery of specialist services. The introduction of NHS-led provider collaboratives in mental health, however, sought to join up the commissioning and delivery of services across pathways of care for children and young people, services for adults with eating disorders, adult low and medium secure services, and secure autism and learning disability services. The transfer of commissioning powers at a national level to local collaboratives provided a mechanism to incorporate local independent sector providers within the wider care pathway and the opportunity to shift the balance of care.

In contrast, the expansion of capacity in core areas of NHS service provision, notably acute and PICU wards, runs counter to national policy and plans. Typically, NHS providers have been reliant on the spot purchase of independent sector beds when demand exceeds local capacity. These placements often result in people being admitted to hospitals a significant distance from home. This can reduce an individual’s access to vital support networks and have a negative impact on the safety and effectiveness of care, in addition to patient outcomes. As a result, the use of such placements for treatment, where the reason is a lack of local NHS mental health acute inpatient capacity, is deemed to be inappropriate. However, our analysis shows not only an expansion in acute bed capacity in the independent sector but also in the number of units and breadth of distribution across the country. Furthermore, independent providers’ websites are often explicit about being contracted by named integrated care systems and NHS trusts to support the delivery of care closer to home. This indicates that the independent sector is playing a more integral role in delivering NHS-funded care – and with a greater number of units and geographical spread those services may now be providing vital capacity at a local level, mediating some of the negative impacts of out of area treatment.

This diversification raises additional questions of accountability and transparency. There have also been notable concerns raised about quality of inpatient care resulting in national intervention. Independent sector providers of NHS-funded care are commissioned under the NHS Standard Contract and regulated by the Care Quality Commission, both of which require them to meet certain regulatory standards. However, unlike NHS providers, common measures used to understand the delivery, effectiveness and experience of care, are not routinely captured from independent sector providers. Furthermore, when data is mandated, such as for people detained under the Mental Health Act 1983, data quality and completeness are notably poorer among independent sector providers.

Shifting the balance of care

Across health care settings there is consensus that intervening early, whether to prevent or limit the impact of ill health, is in the best interests of individuals and population health. However, when people are most unwell, hospital admission remains an important point of intervention for the purposes of treatment and to manage potential risks and adverse consequences of illness. Moving care from hospital to community requires a shift in the balance of care, which enables a greater proportion of people to receive effective treatment and support at the earliest opportunity, while ensuring appropriate access to acute care where it may be beneficial or necessary.

Our analysis highlights that despite significant focus at a national level on expanding the provision of community-based mental health care and alternatives to hospital admission, the scale, scope and effectiveness of these services is currently insufficient to reduce demand for inpatient care to the extent that the NHS is able to meet those needs in a timely way. National policy and financial constraints have limited the option to increase NHS bed capacity, resulting in a gap in care that the independent sector has filled.

The scale of that provision indicates that far from being a temporary solution to current pressures, NHS trusts and integrated care systems have become dependent on the independent sector for delivery. The scope of provision raises important questions about the extent to which the NHS is not only reliant on but has outsourced particular types of care, or the care of specific populations.

There is no blueprint for what the future picture of care should look like and who is best placed to meet those needs. However, far from reaching a meaningful equilibrium, current approaches to shifting the balance of care in mental health have resulted in opaque and fragmented services that few would recognise or could justify.

When people experiencing mental health problems seek help, they should be confident that the services they receive have been commissioned to best meet their immediate needs and are understood and planned within a system of care that is able to address their wider and ongoing needs. Achieving this requires an acknowledgment of the current picture of care, the factors shaping it, and a commitment from policy-makers and commissioners to revisit the balance of care required to meet those needs and who is best placed to deliver it.