Exclusive: Reviews reveal crisis situation in mental health services

HSJ has learned the reviews raise major concerns about Lancashire Care Foundation Trust’s underresourced community services, a lack of crucial bed capacity, inadequate support for patients in crisis, and overstretched accident and emergency liaison psychiatry teams.

The multiple shortcomings have stranded mental health patients in hospital emergency departments with a lack of appropriate support. Lancashire had more than 1,000 cases of patients waiting over 12 hours for admission to a ward in 2018-19, according to statistics published by NHS England, which was a third of all 12-hour breaches nationally. The bulk of these cases were mental health patients.

The situation has led to intense scrutiny from national regulators, and controversial new protocols being introduced that could lead to more mental health patients being admitted to general acute beds.

The outstanding-rated Northumberland, Tyne and Wear Foundation Trust has conducted a review of Lancashire’s mental health system, which is complete and expected to be published next week.

But HSJ has obtained details of some urgent concerns the reviewers raised last December, and are expected to feature in the report.

In an email to the trust’s then chief executive Heather Tierney-Moore, and then director of operations Joanne Moore, the NTW FT reviewers warned some patients were “potentially being held against their will without appropriate legal provision”.

They suggested flow and capacity issues meant some patients were being detained in seclusion rooms for more than seven days under section 136 of the Mental Health Act. This is despite the legislation – which allows somebody to be held “in a place of safety” until they can be seen by a clinician – stating patients can only be lawfully detained for 24 hours, with a possible 12-hour extension.

The reviewers also found that band five nurses with less than two years’ experience were left in charge of a section 136 suite overnight, while staff at one unit told the reviewers concerns had been raised with management and not been addressed.

HSJ has also obtained full details of an external investigation completed in January by consultancy firm Channel 3. Although this took a narrower focus, it is understood to have described similar issues to those identified by NTW FT.

This review outlined the following:

• Lancashire Care does not provide any long-term rehabilitation or high-dependency beds;
• A&E liaison teams are supposed to deliver a “core” 24-hour service but lack the resources to even provide a 9am to 5pm rota;
• A lack of community mental health provision results in more patients deteriorating into crisis situations;
• At night the trust only provides a telephone response to patients in crisis, which places more pressure on police and emergency departments;
• Around a third of section 136 patients are detained for longer than the maximum 24 hours;
• The trust has high bed occupancy, long lengths of stay, and high numbers of out of area placements; and 
• The trust is not making good use of predictive data and is over-reliant on paper-based systems.

Lancashire Care was rated “requires improvement” by the Care Quality Commission last year. Several senior sources in the north west have told HSJ the trust’s relationships with other key partners had become increasingly strained in recent years.

Ms Tierney-Moore retired in March after 10 years in charge of the trust, and Ms Moore has moved into a board-level strategic role. Caroline Donovan became chief executive last month, having previously led North Staffordshire Combined Healthcare Trust to an “outstanding” CQC rating. Russell Patton, formerly of NTW FT, is the new executive director of operations.

The trust was approached for comment.

A report within the trust’s May board papers outlined the latest situation and actions the trust is taking. It said: “There remains fundamental gaps in Lancashire’s bed provision, specifically no commissioned high dependency, long-term complex and learning disability beds.

“The absence of these beds in Lancashire means that patients remain on acute mental health wards waiting for placements to be sourced, a number where the placements are agreed but awaiting a bed… [there is] analysis that demonstrates length of stay for acute admissions is shorter than the national average… but skewed by a tail of stranded patients.”

In a section about additional investment, it added: “The analysis and understanding of the problems coupled with the draft NTW review findings has facilitated constructive discussions with commissioners regarding investment support and priorities.”

The December email to the trust’s former executives, and the Channel 3 report, were released to HSJ after a freedom of information request. The trust and wider system leaders are planning to publish the wider NTW FT review next week.