Memorandum by Independent Healthcare Association
THE REGULATION OF PRIVATE AND OTHER INDEPENDENT
HEALTHCARE (PM58)
SECTION 3: MENTAL
HEALTH AND
SUBSTANCE MISUSE
PROVIDERS
62. This Section builds on Section 2, drawing
attention to issues specific to mental health. This section gives
greater detail on the regulation, monitoring and inspection of
independent sector mental health and substance misuse providers
with inpatient facilities. Under the Registered Homes Act health
authorities register and inspect them (on behalf of the Secretary
of State) as "mental nursing homes". There is no regulatory
concept of a "hospital".
63. There are obvious differences between
mental health and acute medical/surgical provision in terms of
appropriate staffing, treatments and facilities. Independent mental
health providers have, in addition to registration requirements
under the Registered Homes Act, an extra layer of regulation—the
Mental Health Act and Commission. They are also different from
independent sector acute medicine/surgery provision because a
significant proportion of their services are purchased by the
public sector. Health Authorities that purchase care from the
sector, either on contract or more typically by spot purchasing—usually
referred to as "ECRs"—include in the contract
the right to monitor and inspect providers.
Acute and Non-acute Care
64. The independent mental health sector
can broadly be divided into two according to type of patient,
length of stay and funding source: acute psychiatry and substance
misuse treatment and non-acute psychiatric care. Acute psychiatry
covers patients with acute psychiatric illness, length of stay
is shorter than for non-acute psychiatric care and funding is
either from private medical insurance (though many PMI policies
exclude mental health cover) or increasingly from health authorities
either on contract or spot purchased. Substance misuse services
are also mostly spot-purchased by health and/or local authorities.
Medium secure care is categorised here as acute care and usually
spot purchased on "ECRs". Acute care is delivered in
mental nursing homes though the term is misleading and these facilities
are in reality psychiatric hospitals some with up to one 100 in-patient
places or more.
65. Non-acute psychiatric care is usually
not covered by PMI policies though other types of liability insurance
may cover it. It includes brain injury rehabilitation, rehabilitation
of the mentally ill, people with learning disabilities who have
challenging behaviour and long term care of people with psychiatric
disabilities. Funding comes largely from the NHS spot purchasing,
income support or local authorities. In-patient stays are usually
months or years as opposed to weeks or days in acute care.
66. Some services do not fit neatly into
these categories of acute and non-acute care. Medium secure care
is categorised as acute care in this submission however length
of stay is often months. Substance misuse, adolescent psychiatry
and treatment for eating disorders typically requires initially
acute psychiatric treatment followed by non-acute care. Long-term
care including care for the elderly mentally ill (EMI), and care
for people with learning disabilities is provided in nursing and
residential care homes. EMI services are not dealt with specifically
in this evidence but further information on nursing homes is presented
in Annex 3.
Overview of the Sector and Providers
67. According to Laing (1998) there are
73 independent hospitals or units in the UK providing acute psychiatric
care and/or substance misuse inpatient treatment. Ten of these
units are in independent hospitals also providing acute medical/surgical
treatment. Laing (1998) estimates a total of 2,377 acute psychiatric
or substance misuse beds (excluding medium secure) with a market
value in 1997 of £94 million. Due to the significant numbers
of substance misuse places registered by local authorities as
care homes this figure underestimates the total number of residential
substance misuse services.
68. There are 909 additional independent
medium secure beds representing over 30 per cent of the UK's total
medium secure provision. Partnerships in Care is the single largest
provider of independent medium secure beds and provides 18.5 per
cent of the total number of beds (including the NHS). St Andrew's
hospital Northampton provides 7 per cent of the total number of
medium secure beds available.
69. In the past few years the sector has
diversified into specialist areas of provision such as eating
disorders and adolescent psychiatry. For example, Laing (1998)
reports that there are 31 independent sector specialist units
treating eating disorders. Other significant niches of provision
include low/medium secure care, 24-hour nursed care, and brain
injury rehabilitation. Registered mental nursing homes provide
80.6 per cent (205 beds) of brain injury beds the NHS providing
the rest. St Andrews, Partnerships in Care and Westminster Health
Care between them provide the vast majority of services.
70. The three largest acute psychiatric
providers (excluding medium secure care) Priory Hospitals, Charter
Medical and Cygnet operate 41 per cent of the acute psychiatric
sector's bed capacity. The next largest St Andrew's Group has
7 per cent of the market total.
71. The largest providers of non-acute psychiatric
care including medium secure care are Partnerships in Care (the
single largest provider) Westminster Health Care and St Andrew's
Group. Excluding mental health beds for the EMI and acute psychiatry
Laing (1998) estimates that 67 per cent of beds for non-acute
psychiatric care are provided by independent registered nursing
homes and residential care homes.
Employed Consultant Staff
72. More than acute medical/surgical hospitals,
independent psychiatric hospitals often employ consultant staff,
or have a mixture of employed, retained and self-employed consultants.
An IHA survey found that the consultants employed either full-time
or part-time in the independent mental health sector represented
11.5 per cent of all consultant psychiatrists in post. The number
of consultant psychiatrists doing some work in the sector including
those with admitting rights represents almost a quarter of all
consultants in post.
Funding
73. The vast majority of acute mental health
care in the UK is provided and financed by the NHS or local authorities.
Laing (1998) estimates that about 9 per cent of all acute psychiatric
beds are provided by the independent sector: 6 per cent privately
financed via self-pay or PMI and the remaining 3 per cent financed
by the NHS. The NHS funds about 30 per cent of independent sector
acute psychiatric beds. These are probably underestimates due
to uncertainty about the numbers of acute NHS mental health beds
and differences in classifying what constitutes acute (as opposed
to non-acute) psychiatric care. Further, significant numbers of
substance misuse providers are registered by local authorities
as residential care homes. A report commissioned by the Department
of Health and the IHA from the Sainsbury Centre for Mental Health
(1995), now somewhat outdated, estimated then that 17 per cent
of total acute provision was provided by the independent sector.
Industry sources would put the figure as high as 20 per cent.
The majority of long-term care for mental illness is financed
by the NHS, local authority and/or income support.
Registration and Inspection
74. Like independent sector medical/surgical
hospitals acute mental health and substance misuse services are
registered and inspected by their local health authority registration
unit according to the terms of the Registered Homes Act and associated
regulations. A significant proportion of substance misuse services
and long-term care services are registered by their local authority
or dual registered. There are concerns about the appropriateness
of registering residential substance misuse services and some
long-term mental health care services as registered care homes
with local authorities where a significant element of care is
deemed health as opposed to social care.
75. HA registration officers make regular
and increasingly more stringent inspections of registered nursing
homes in their patch. Relations between providers and registration
officers industry-wide are largely positive. However, qualified
nursing and medical staff, consulted to inform this submission,
who have experience of both the statutory and independent sectors
report that the standards required of independent sector providers
as a condition of registration are higher and often much higher
than evident in the NHS and they vary from HA to HA. They also
report that the focus of inspections and the composition of the
inspection team in terms of relevant qualifications are often
inappropriate. There is frequently an undue emphasis on hotel
standards such as décor and not sufficient emphasis or
psychiatric expertise into inspecting standards of treatment and
care.
76. For example substance misuse providers
report registration officers are not sufficiently informed about
quality standards of treatment and therapy. The appropriateness
of referral and indeed acceptance of the referral by the provider
is not monitored. Acute psychiatric providers report that the
failure of health and local authority purchasers to fulfil their
obligations under section 117 of the Mental Health Act requiring
their input into pre-discharge planning is known but persistently
not corrected. Hotel standards (eg furnishings and decoration)
are expected to be much higher in the independent sector than
in equivalent units in the NHS.
77. Overall there is a general feeling that
the registration and inspection process could be improved. It
should be more relevant to care and treatment standards and these
standards should be explicit and capable of systematic audit.
The registration team needs to be sufficiently expert in terms
of qualifications and experience. Providers themselves from other
similar hospitals (independent and statutory) could make a useful
contribution to inspections and be invited to join inspection
teams, as could assessors from the Royal College Psychiatrists.
Standards should be consistent across the UK and the same standards
that are expected of the independent sector should also be required
and monitored in the statutory sector.
78. The principle that public sector funded
patients should expect and receive the same standards of care
and treatment irrespective of geographical location or provider
sector (statutory or independent) should be built into the statutory
registration and inspection process.
Mental Health Act 1983 and Commission
79. Under the Registered Homes Act 1984
mental nursing homes may only detain patients under the Mental
Health Act 1983 if specifically registered to do so they must
then comply with all the provisions of the Act. The commission
has a statutory duty to visit detained patients in registered
mental nursing homes. The Mental Health Act Commission reports
the total number of beds and admissions to independent sector
providers as increasing. Providers range from large hospitals
providing medium secure care to small homes where there may be
only one or two patients detained under the Act (MHAC, Seventh
Biennial Report 1995-97, HMSO, 1997)
80. Each registered mental nursing home
receives a Full Visit and at least three Patient Focused Visits
in a two-year period, with medium secure units at least one a
year. As part of the Patient Focused Visit, Commission members
collect information in a standardised format on key issues. Additionally,
targeted visits are undertaken to examine specific issues, which
may be a matter of particular interest. Targeted and Patient Focused
Visits may be unannounced or at short notice. Reports from visits
are sent to the providers and the registering health authority.
The Commission also publishes a Biennial Report documenting its
findings from visits including naming units exhibiting good and
bad practice.
81. The Commission has stated a particular
interest in independent sector medium secure units because of
their size and significance. Kneesworth House, Stockton Hall,
Llanarth Court, Redford Lodge (all four operated by Partnerships
in Care) and St Andrew's Northampton are frequently inspected
by the Mental Health Act Commission.
82. Relations between the Mental Health
Act Commission and independent sector providers are very good.
The sector as a whole welcomes the diligence and expertise of
the Commission and finds its reports and recommendations for service
development and improvement helpful. Sector representatives in
membership of the IHA meet formally at least once a year with
representatives of the Commission to discuss developments. Despite
its role as an inspectorate, the Commission is experienced by
the sector as accessible, informative, and conducive to service
developments and improvements.
83. The Mental Health Act 1983 is currently
under review. Independent sector providers individually and through
the IHA are in contact with the review team. The IHA mental health
division is running an industry-wide consultation on the scope
of the review issued by the review team and to be submitted by
the end of January 1999.
Regulation by purchasers
84. Registered mental nursing homes are
also subject to monitoring and inspection by the statutory purchasers
of care. Purchasers usually provide for this with clauses in their
contracts. In practice only purchasers with a significant financial
investment in a particular unit will visit, inspect and monitor
the provider. Typically, several different health and/or local
authorities will fund patients in a registered acute or non-acute
mental nursing home. Organisations providing exclusively substance
misuse services report that inspection and monitoring by statutory
contractors is negligible.
85. The Commission drew attention in its
Sixth Biennial Report to its concerns about the lack of monitoring
and inspection by purchasers of medium secure care. Places are
purchased in these units by large numbers of HAs. A lead purchaser
arrangement to undertake monitoring at a particular hospital on
behalf of all the other purchasers has been put in place by the
NHS. This arrangement has not been entirely successful. As a result
providers have developed and put in place service level agreements
with purchasers.
86. In July 1998 the government published
Commissioning Specialised Services, which proposes the setting
up of regional specialised commissioning groups. Regional offices
of the NHS are to take responsibility for ensuring that effective
arrangements are in place for commissioning specialised services
and setting up commissioning groups. The definition of specialised
services includes services where there are frequent referrals
to the sector including medium secure care, brain injury rehabilitation,
treatment for eating disorders, and in-patient child and adolescent
psychiatry. The sector is awaiting further guidance and information.
The role of the new groups in regulating and inspecting services
is unknown. There is a strongly held view amongst independent
providers that these groups preferably via representation on the
group should formally consult them.
87. Private medical insurers are increasingly
getting involved in the monitoring of care they purchase. By the
end of the 1980s medical insurers were targeting psychiatric care
as a speciality particularly amenable to cost containment through
managed care initiatives. Pre-authorisation and utilisation reviews
are standard practice. The introduction of provider networks and
treatment protocols in the 1990s continue the process of cost-containment
through monitoring and regulation of care.
The Government's Mental Health Strategy
88. The absence of formal processes and
requirements on the part of the NHS to include the sector in the
planning, development, and provision of mental health services,
including specialised services, is of considerable concern to
providers. Modernising Mental Health Services the government's
mental health strategy published in December 1998 makes no mention
of the independent sector beyond para. 4.59 which refers only
to the importance of working in partnership with the voluntary
and charitable sector. In the light of the information provided
in this submission about the range and volume of mental health
care provided by the independent sector, particularly in the areas
highlighted for development in the strategy such as secure, acute
and 24-hour nursed care, the sector wishes to have a greater input
into policy development and planning.
89. The status of the sector with respect
to the government's recently announced quality and clinical governance
framework is also unknown. The relationship between independent
sector mental health providers and the National Institute for
Clinical Excellence (NICE), National Service Framework (NSF) and
Commission for Health Improvement (CHI) is unknown. The publication
of the mental health NSF is expected in April. The sector was
not granted representation on the government's external reference
group that devised the mental health strategy nor any of its numerous
sub-groups. Similarly the sector was not granted consultation
with the body appointed under Professor Thornicroft developing
the NSF. In future the sector would like to be more closely involved
with planning and policy development bodies.
90. The sector welcomes the government's
national quality standards initiatives. The view of the sector
is that independent mental health providers should be acknowledged
for the significance of their contribution and included, in the
same manner as NHS and local authority providers, in the new quality
of care standards framework currently being set up.
Self-regulation
91. Independent mental health and substance
misuse treatment providers in membership of the IHA have developed
and implemented a considerable number of quality assurance initiatives.
All IHA mental health members are required as a condition of membership
each year to sign up to the IHA's quality assurance policy which
requires members to participate in an IHA approved quality assurance
scheme. For approval schemes have to be externally operated, credible,
whole hospital and directed at service quality. Schemes approved
include King's Fund Health Quality Service, ISO9000 series,
EATA Towards Standards for Drug and Alcohol Services, and
(once fully developed) the Health Advisory Service 2000. Members
are also required to sign up to the IHA's Code of Practice for
Psychiatry and Substance Misuse Membership (see Annex 8).
92. Representatives of all the sections
of the Royal College Psychiatrists meet with representatives of
the IHA mental health membership on a regular basis through the
RCPsych/IHA Liaison Group set up in 1995. The group is chaired
by the Registrar of the College. The focus of the group is quality
standards. Joint initiatives to date include manpower and training
standards surveys, a consultant appointment process for posts
in the independent sector, confidentiality and discharge guidelines
for providers of care for the EMI, series of papers focusing on
quality issues at the interface of the independent sector and
NHS covering to date, EMI, forensic psychiatry and psychotherapy.
Patient Complaints
93. The IHA approved quality assurance schemes
and code of practice include best practice with respect to complaint
policies and procedures, which will be boosted by the revision
of the Code of Practice on Patient Complaints. Providers treating
NHS funded patients are also subject to the complaints handling
requirements and procedures of their statutory purchasers including
ultimately access to the NHS Ombudsman for NHS funded patients.
Summary: Mental Health
94. The independent mental health and substance
misuse sector is a sizeable and growing contributor to acute and
non-acute mental health services in the UK.
95. Independent providers of mental health
and substance misuse provision welcome inspection and regulation
and view it as a valuable process in enhancing the quality of
patient care. The sector is already heavily regulated, more so
than equivalent services in the statutory sector. Current regulation
by registering HAs is variable and patchy. Registration teams
are frequently insufficiently expert and focus on facilities as
opposed to treatment and care.
96. The status of the sector with respect
to the government's newly announced clinical governance framework
and mental health strategy is unknown. The sector would like to
be more closely involved with the planning and consultative bodies
set up to devise the latest mental health policies.
97. The sector welcomes the Mental Health
Act Review and continues to operate productively under the Mental
Health Act Commission.
98. The principle of equity of regulation
for providers of similar services across the NHS and independent
sectors should apply for the benefit of patients.
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