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.
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.
ReplyDeleteHow 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
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.
DeleteYour blog rightly highlights the absurdity of the current system of commissioning inpatient psychiatric services.
ReplyDeleteAs 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.
A lot of the nhs hospitals have even worse reports lol
ReplyDeleteThat may be true, but why pay vastly over the odds for private hospitals to be crap? Give the money to the NHS to improve their own hospitals.
Delete