Lack of staff and beds leading to ‘harmful’ gaps in mental healthcare, warns CQC

A lack of staff and hospital beds, at a time of “overwhelming demand”, is leading to “harmful” gaps in mental healthcare, the Care Quality Commission (CQC) has said.

As a result, people were being discharged prematurely, often without adequate community support, leading to cycles of readmission to hospital, with increasing use of inappropriate out-of-area placements.

The warnings came in the regulator’s annual report on its monitoring of the Mental Health Act 1983, which covered 2023-24.

This was based on conversations with 4,634 patients and 1,435 carers from 823 monitoring visits to mental health services, interviews with other people with lived experience of detention and analyses of national data on mental health.

Spike in demand for care

Demand for mental healthcare has grown significantly in recent years, said the CQC, which reported that:

• There had been a 43% rise in the number of people in contact with secondary mental health services in the five years to March 2024, according to NHS England’s mental health services data set (MHSDS).
• There was an 18% increase in the number of adults with a serious mental illness who accessed community mental health services between March 2023 and March 2024 (source: MHSDS).
• The number of very urgent adult referrals to crisis teams more than doubled in 2023-24.

The latter figure suggested that people were becoming more unwell while waiting for help than was previously the case.

People ‘more unwell on admission than in the past’

This was reflected in services reporting that people admitted to hospital under the MHA now were more unwell than in the past, which the CQC said could increase recovery time and made it more difficult to admit new patients.

However, inpatient services lacked sufficient beds, which meant that occupancy levels in mental health wards continued to be much higher than the 85% maximum recommended by the Royal College of Psychiatrists. Since the start of 2023-24, the occupancy rate has ranged from 89.6%-90.6%, according to the college.

The pressure on beds meant people were placed on wards that were not suitable for them. For example, the CQC observed that people with dementia or cognitive impairments had been placed on wards for those with functional mental health conditions, meaning they were not cared for in dementia-friendly environments.

In another case, seclusion rooms – which are designed to segregate patients from others in times of crisis – were being used as bedrooms due to bed shortages, meaning people were being cared for in overly restrictive settings.

Rising numbers of out-of-area placements

The situation was also leading to people being placed in hospitals far from home, with official figures showing there were 5,500 new inappropriate out-of-area placements in 2023-24, up 25% on the previous year, the CQC said.

The regulator cited a report last year from the Health Services Safety Investigations Body (HSSIB), which found that people were being harmed by OAPs, due to the increased anxiety of not knowing new staff and being separated from support networks.

The CQC said it saw “multiple examples” of people being placed out of area, without clinical benefit, because of a lack of local beds.

‘Pressure to discharge least unwell patients’

The pressures on wards meant managers felt they had to discharge the “least unwell” patients, with carers also telling the CQC that loved-ones had left hospital too soon.

The regulator found examples of good practice in the provision of post-discharge support, however, this was affected by the pressures on community services, which increased the risks of readmission.

Though the MHA code of practice states that aftercare, provided under section 117 of the act, should encompass health, social care, employment support and supported accommodation, as required, the CQC said its provision was “often far less holistic” than this.

Lack of staffing

Service pressures were exacerbated by a lack of staffing, despite a 35% rise in the number of full-time equivalent mental health workers in the NHS from 2019-24.

Issues included wards not having a permanent responsible clinician, multiple wards not having occupational therapists available and others not having physiotherapists.

Staff shortages led to activities, such as group excursions, day trips and access to gyms, being delayed or cancelled, and patients being prevented from taking authorised leave, potentially delaying recovering and leading to distress.

The situation was leading services to use agency or bank staff, resulting in a lack of continuity of care for patients and, sometimes, poor interactions between staff and patients.

Also, shortages and a high turnover of care co-ordinators in the community led to challenges with the discharge process.

In addition, the CQC found that gaps in staff knowledge were affecting the quality of care for autistic people and those with a learning disability, with some staff having not completed mandatory learning disability and autism training.

People’s rights not explained to them

Other issues cited by the regulator included cases of people not understanding their rights under the MHA. This included:

• patients not being informed of their rights at admission or significant delays them being informed after admission;
• staff not providing updates to patients on their legal rights when the section of the act under which they were detained changed;
• patients not being referred to an independent mental health advocate (IMHA) when they did not understand their rights;
• legal rights information not given in a person’s preferred language.

‘Legislation alone won’t fix issues’

The report comes with the government legislating to reform the MHA in order to reduce the use of detention, improve patients’ rights over their care and prevent autistic people and those with learning disabilities from being detained without a co-occurring mental health condition.

While acknowledging the aims of the Mental Health Bill, the CQC said the sector’s problems could not be fixed by legislation alone, in the absence of additional resource.

“It is essential that the government addresses these significant gaps now to protect people for the future,” said the regulator’s interim director of mental health, Jenny Wilkes. “With the right funding, a sustainable and well-trained workforce and enough beds to meet demand, we can break this damaging cycle.”

‘The very opposite of dignified, humane care’

In response to the report, the chief executive of the charity Mind, Sarah Hughes, echoed the CQC’s calls for greater investment in community care, the workforce and mental health facilities.

“Fundamental problems with the very basics of safe care, like adequate staffing levels, bed capacity and run-down hospitals, are severely impacting people’s ability to properly recover,” she added.

“Being sent hundreds of miles away from your family and loved ones, and not even being able to contact them due to facility issues, would be difficult enough at the best of times, let alone when you’re experiencing a mental health crisis. Isolating people in this way, and holding them in crumbling, outdated facilities, is the very opposite of dignified, humane care.”