Friday, 10 May 2019

What’s the point of private psychiatric hospitals?


Once upon a time, in a galaxy far far away…

Once upon a time (about 20 years ago) NHS psychiatric hospitals had enough beds for anyone who needed to be in hospital. Indeed, often, the local unit I admitted to would frequently have a 10% under occupancy rate. This meant that imaginative uses could be put to these beds, such as brief respite admissions or even allowing patients to contact the hospital themselves to ask for admission as part of a crisis care plan.

It was exceedingly rare for beds (other than some specialist beds such as eating disorder units) to have to be obtained from out of area, in which case, one or two moderately local private hospitals would be used. Patients would then be brought back into the locality NHS hospital within days.

Back then, private hospitals were almost exclusively used by private patients who were well off enough to have private health insurance.

I recall working with a patient back then who was admitted privately under s.2 . He was experiencing an acute psychotic episode.

His parents, who were extremely wealthy, arranged for him to see a private psychiatrist. This psychiatrist, who was also a locality NHS psychiatrist, assessed him and concluded he needed to be detained. As he also worked part-time for the private hospital, he arranged for admission there.

The patient appealed, and I provided a social circumstances report and attended his Mental Health Tribunal.

In preparation for this, I spoke to the psychiatrist who had seen him. He told me that he was referring him to our local CMHT psychiatrist, and would not continue to see him privately. This was because “I only see private patients if there’s nothing seriously wrong with them.”

I am using this story to illustrate the difference back then between NHS and private psychiatric hospitals: NHS hospitals admitted “proper” patients, while private hospitals concentrated on anyone who could afford to pay, whether there was anything significantly wrong with them or not.

I know this is an appalling generalisation, but there is at least an element of truth there.

But over the last 10 years in particular (is it a coincidence that this has been during the Coalition/Conservative period of austerity? I think not) all this has changed. As NHS hospital beds have been cut back and cut back, there has been a corresponding vast increase in the use of private hospitals by NHS Trusts, at enormous expense.

While there may be a case for seeking specialist beds in private hospitals, for example, for eating disorders, most of these private beds are simply for acute adult admissions.

The most recent statistics for detentions under the MHA give a breakdown of those detained in NHS psychiatric hospitals and those detained in independent hospitals. Independent hospitals are hospitals either run for profit, such as the Priory Group Hospitals, or operated by charitable trusts, such as St Andrews Healthcare.

On 31st March 2018 there was a total of 15,918 patients detained in hospital. Of these, 12,555 were in NHS hospitals, while 3,330, or 21%, were in independent hospitals.

Are independent hospitals any good?

One might expect private hospitals to be able to provide exceptional care, since they are privately funded (or are they? I’ll come to that).

It’s not necessarily been my experience.

One incident concerns an extremely unwell and psychotic patient who was admitted from the community under s.3 to a private hospital. She was there for about a week when I received a call from a nurse on the ward. She told me that the patient had absconded 3 days earlier, and wanted to know if, as she was no longer in hospital, she could be discharged from s.3. The hospital had made no effort to inform the police, or even bother to tell me as the care coordinator at the time.

Who funds private and independent hospitals?

St Andrews Healthcare’s annual report for 2016-17 states that NHS England is its biggest source of funding.  It says: “The Charity receives essentially all its income from NHS entities.”

NHS England reported that it has directly purchased £294,796,282.22 of services from St Andrews Healthcare over the period January 2014 to July 2017. 

In February 2018 St Andrews Healthcare Nottinghamshire was rated by the CQC as “inadequate”.


Staff at the hospital did not adhere to the Mental Health Act Code of Practice when using seclusion, and staff allowed patients on one ward to vote on whether to end or continue other patients’ seclusions.

Inspectors identified several potential ligature anchor points, placing patients at risk with out of date risk assessments – contributing to the CQC’s assessment that “staff did not protect patients from avoidable harm or abuse.

Patients told the inspectors that, on some wards, staff ignored them and did not respond to basic requests, such as for going to the toilet and for food and medicine.

St Andrews Healthcare is not the only organisation providing psychiatric inpatient care that obtains large amounts of NHS money. In fact, it has been my experience that most private hospitals are very keen to take money from the NHS for patients.

One example is a private hospital that will only consider the admission of an NHS patient if it can be guaranteed that the patient will remain with them for at least a month. This seems to fly in the face of the principles of the MHA which stresses that detention should not last longer than absolutely necessary.

I am also aware of the case of a 15 year old child with a diagnosis of Obsessive Compulsive Disorder and Autism who was detained under s.2 in a general hospital because of problems over low weight. He was assessed by the eating disorders service who concluded that he did not have an eating disorder, but needed a specialist bed for his OCD and autism. Instead, he was placed in a private eating disorders specialist unit.

The unit requested detention under s.3 for treatment. His care coordinator, who was also an AMHP, assessed him with a 2nd s.12 doctor. They both concluded that the patient did indeed not have an eating disorder, and therefore treatment in an eating disorder specialist unit could not be justified. As he was agreeing to remain as an informal patient, the s.2 was allowed to lapse.

The unit continued to treat him for an eating disorder, and wilfully downplayed his actual mental health problems. But they were very reluctant to allow him to be moved on.

And one final anecdote. This concerns a 16 year old girl who was detained under s.2 in a private hospital. Her care coordinator arranged for her to live in special accommodation in her home area in order to attend 6th form college. Her community psychiatrist was fully on board with this. However, the hospital psychiatrist refused to discharge her from her section, so she lost her accommodation and could not start her course.

You’d be forgiven for thinking that the reasoning behind this refusal was more to do with financial considerations that the needs and welfare of the patient.

The Priory Group

The Priory Group is probably best known for providing drug and alcohol detox programmes for high profile celebrities, but it is one of the biggest private mental health care providers in the country. In 2017 it had an operating profit of £2million.

On 17.04.19. the Priory Group was fined £300,000 over the death of a 14-year-old girl, Amy el-Keria, in their hospital in Ticehurst, East Sussex, in November 2012. Amy had a recent history of self-harm and suicide attempts and was found hanged in her room, a room that had been assessed by an untrained staff member to have “medium risks” with a number of ligature points, but this assessment had not been followed up. There was a catalogue of poor and negligent practice. Staff did not promptly call 999 or a doctor and were not trained in CPR. The hospital’s lift was too small to accommodate the ambulance service’s stretcher. Nobody from the hospital went with Amy in the ambulance.

And if you’re thinking that the Priory Groups private patients might be treated with more respect, consider the recently reported case of PB v Priory Group Ltd [2018] MHLO 74. I am grateful to Matthew Seligman of Campbell-Taylor Solicitors (solicitors for the claimants) for summarising this truly disgraceful case.

As a private patient PB attended an outpatient appointment at the Priory Hospital (North London) in September 2018. In the first 15 minutes of the consultation she was told that she was being detained under s.5(2) MHA. She ran out of the room, but was prevented from leaving and was admitted to a ward.

Readers of this blog will probably now be exclaiming, “But s.5(2) only applies to inpatients! It can’t be imposed on someone merely visiting a hospital!”

You’re absolutely right.

To add insult to injury, the person’s husband, who had also attended the appointment, had to make an immediate down payment of £10,626 on his credit card, as the Priory charged £834 per day.

She was then detained in hospital for a total of 17 days. This included 72 hours under the illegal s.5(2), which was allowed to expire without assessment for s.2, meaning she was detained for a further 7 hours without any form of legal authority, until an application under s.2 was finally made. She was eventually discharged by the hospital psychiatrist on 17th October 2018.

To make things even worse, if that’s possible, the hospital then pursued the couple for outstanding fees of £3,000. I assume that they felt this was more than a step too far, because the patient and her husband then brought proceedings against the hospital, claiming damages for the whole period of the wife’s stay for unlawful detention and breaching her human rights under Article 5. The couple accepted an offer of £11,500 plus legal costs.

Despite these horror stories, I am not suggesting that all private psychiatric care is poor, and in fact I have a lot of experience of very good, humane, patient centred treatment from some private hospitals.

But I will question why the NHS is spending so much more on private psychiatric provision, when it does not even guarantee an acceptable level of care.

NHS psychiatric beds should be available for NHS patients when needed. The Government should be providing sufficient funds for the NHS to be able to ensure this.

Private psychiatric hospitals should only be required for patients who want to pay for their private care.

3 comments:

  1. When AMHPs detain please explain why a private hospital known to be unsafe and miles away from the support community is considered better and safer than community least restrcictive options. And there lies the rub. Instead of most AMHPs shouting from the roof tops AT the MH Trust AT the CCG they instead endorse the awaful abusive practices you've rightly highlighted. So MH Trusts and CCGs can continue to say that the MH professionals detaining havent ever raised objections about placements in tne private sector even the light touch CQC describe as obviously unsafe and in breach of every protective legislation in place.

    How about this? AMHPs place the human rights at the centre of decisions, demand that the identified bed is fit for purpose by actually checking rather than walking away.
    I speak as someone who has been detained. Several times. The professionals I personally feel have let me down the most in crisis are AMHPs .Because like it or not as a group you have incredible power.And turning a blind eye is an abuse of that power

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    1. The AMHP's role is to assess whether or not a person needs to be detained in hospital. It is the job of the doctors to find a hospital bed. The AMHP has no control over where this bed is. In reality, an AMHP may have to make a choice as to whether to accept a bed many miles away, or to defer the application until a bed is found. If the risks are too high to leave the person in the community, then an AMHP has little choice but to make an application to an out of area bed, which is likely to be in a private hospital.

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  2. Your blog rightly highlights the absurdity of the current system of commissioning inpatient psychiatric services.

    As we know this is political. People lazily complain about the decisions of mental health professionals at the time of the mental health act assessment, but some of these people are commissioners who present no other meaningful options to prevent that admission. There appears to be a fundamental confusion or conflation that all mental health problems require the same intervention, ie "how come that person with difficulties related to their personality needs is being admitted when that other person with mild anxiety was supported by the Gp alone". Clearly this isn't the case. I have sat in rooms with NHS mental health commissioners who have told me amhp are detaining too many people, but don't have a background in the delivery of frontline mh services.

    So that is a very long way round of saying the system is set up to marginalise people who already are largely marginalised (when considered in the broader context of issues around employment, poverty,claiming benefits, poor housing, remote public services amongst other concerns). The profit motive brings nothing to the delivery of complex mental health services and creates inefficiency (how can it be efficient, let alone therapeutic, to admit someone a hundred miles away and then expect local services to follow up interventions with them?)

    Whatever the limitations of the NHS acute admission provision should always be local to an NHS bed.

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