Further than ever

Laura Davis was more than 200km away from home – the first time she had ever spent time away from her family – when she took her own life in her bedroom in a mental health unit in Warrington on 20 February 2017.

The 22-year-old had been transferred to Arbury Court from a hospital in Gloucester, near her Cheltenham home.

Laura – described by her family as caring, intuitive, and fiercely protective of family and friends – was a survivor of sexual assault, with a diagnosis of emotionally unstable personality disorder. She had a history of self-harm and had been detained under the Mental Health Act in June 2016.

The move to the Warrington facility, which took place in November 2016, was intended to be short-term, in lieu of a more appropriate long-term treatment option. But three months later, she was still there when she died by suicide.

Following an inquest earlier this year, the coroner noted a number of failings in Laura’s care.

The published record of inquest said ‘deficient’ information regarding a history of incidents involving Laura had been passed from one hospital to the next, that communication ‘between all parties’ was ‘inconsistent’ and described a ‘serious failure’ in communication between staff at all levels regarding an incident involving a potential ligature. Concerns were also noted around unsafe practices of high-risk items being given out to patients.

A spokesperson for Elysium Healthcare, which runs Arbury Court, gave the provider’s ‘unreserved apologies’ for the shortcomings identified in the inquest, and said important lessons have been learnt to ensure better communication.

Laura’s mum, Joanna Davis, says she felt powerless with Laura so far away from home.

‘Being the parent all you can do is love your child when they’re on those units – you feel you have no say in where they are, you are so far away and you don’t feel like you have a proper voice,’ she says.

‘She never got home… That’s my biggest regret.’

It is a story which speaks to many of the concerns doctors, patients and families have about the state of NHS mental healthcare across the country.

Before the pandemic, rates of mental illness in England were increasing and mental health services received record numbers of referrals last year. On top of that, the workforce is under increasing strain with around one in seven planned FTE (full-time equivalent) doctor roles vacant and many more filled with temporary staff.

Vacancy rates are even worse for nursing roles – standing at 18 per cent of posts as of last December. Funding is a significant issue, too. In recent years spending on mental health has increased at a slower rate than overall NHS expenditure and the proportion of the NHS England budget spent on mental health has fallen since 2016/17.

One of the gravest results of this chaotic concoction of rising demand, a beleaguered workforce and dwindling resource, is that hundreds of vulnerable mental health patients are sent to hospitals miles away from home every month in England. The NHS simply does not have enough beds or enough staff to meet the need in communities.

The latest data, published by NHS England this month, showed that 380 patients were sent OOA inappropriately during January 2023 alone. Of those patients, 59 per cent were placed more than 100km away from home and 46 per cent were on those hospital wards for more than 30 nights.

Almost all these beds are run by private firms and come at a significant cost to the NHS.

These new figures come two years after the Government was supposed to have eliminated this painful separation of patients and families. In 2016, the then health secretary, and now chancellor, Jeremy Hunt, said not a single patient from England with acute mental ill health should be in a bed far from home for want of one locally.

That target was supposed to be hit by the end of March 2021.

‘That we are still in this position – with hundreds of people being sent so far away from home – even with the health secretary who made these promises now holding the purse strings of this country, suggests we simply do not value the lives of these incredibly vulnerable people,’ consultant psychiatrist Andrew Molodynski says.

Academic research into the effect of OOA placements is limited – and data looking at outcomes isn’t collected nationally. Studies have, however, found there is little evidence of people admitted to OOA beds being given community support afterwards, and a commission reviewing this care in 2016 found patients are left feeling isolated and recovery is delayed.

Patients, doctors and families report issues with record keeping and sharing, a lack of continuity of care, the breakdown of vital relationships between clinicians and patients and already often vulnerable and isolated patients feeling even more forgotten and uncared for.

Rising OOA placements are ‘one of the best markers that we’ve got of poor quality of struggling mental health services’, Yorkshire consultant in public health Emma Pearce says.

Dr Pearce, who specialises in public mental health, adds: ‘It’s poor quality for your patients because you lose your therapeutic relationships, you lose your family relationships and that reintegration back into your local area. The quality of services in OOA placements is also really difficult to assure.

‘One of the things that keeps coming up time and time again is the shared patient record, the shared understanding of that patient. Often, once they’re in somebody else’s service, you’ve got little idea what’s going on with them and you’ve got no easy way of assuring that quality.’

James Eldred, a consultant psychiatrist in the south-west of England, says sending people who often have difficult relationships with family and friends a long way from home can also create ‘a sense of malignant alienation’ – of being ‘unwanted’.

Fifteen-year-old Eve Reynolds,^* who has a diagnosis of ADHD and is undergoing tests for autism, was sent 145km from her home in Cheltenham to tier four CAMHS hospital Taplow Manor in Maidenhead last month. In the first three weeks her family clocked up almost 3,000 km driving back and forth to visit.

‘She was taken in a secure van, driven 90 miles away and that was basically that,’ Eve’s dad, Joe Reynolds, says. ‘Imagine what that must be like, to be told you’re going so far from all of your family when you’re already suffering.’

Her detention to a secure unit followed her being sectioned into Gloucestershire Royal Hospital, where she was kept under 24-hour surveillance in the children’s ward and given injections, after instances of self-harm.

‘We were told we were lucky to get a bed at all,’ Mr Reynolds tells The Doctor. ‘It was getting to a point where it was very serious. We just want her to be safe. I could’ve said “no”, but the next one available might have been even further away.’

While the latest figures show a decrease in the number of inappropriate OOA placements – placements where the distance isn’t justified for reasons such as safeguarding or complexity – the total number of placements still active at the end of the month has been consistently higher than when the Government’s target was set.

In January 2023, there were 620 continuing, compared with 504 in November 2016. The number of days patients spent in OOA placements during the month has rocketed from 11,183 to 18,425.

Deborah Park’s 13-year-old daughter was transferred from a general hospital in Leeds to a mental health bed in Sheffield in December 2021, having been diagnosed with anorexia.

Owing to rush-hour traffic, Ms Park says round trips would often take four hours and sometimes, owing to the unstable nature of her daughter’s illness, she wouldn’t even get to see her.

‘It’s difficult to ask people to find a four-hour block in their day for a visit, especially when they might not even get to see her,’ she says. The anorexia also meant her daughter couldn’t sit down – and was often wandering around wards for 13 hours a day. This resulted in trips home being impossible because she couldn’t sit in the car for long enough.

The situation also affected her other child, who was taking GCSEs at the time. ‘She felt like I was never here. I was always going to Sheffield.’

The latest data shows a worrying trend in the distances patients are sent from home. When the target to eliminate OOA placements was set, just 24 per cent of placements were more than 100km away.

During each of the last 22 months that figure has been between 50 and 62 per cent. On top of that, 29 per cent of patients are now being sent more than 200km from home and a further 9 per cent are sent more than 300km away.

These figures are all higher now than they were in March 2021, when the practice was supposed to have ceased.

One patient was sent from a hospital in Devon to a private facility in Darlington, some 540km away. Every visit would cost around £104 in fuel or £212 with an open return train ticket. Further journeys include Essex to Northumberland and Newcastle to Bristol – each around a 300-mile trip.

Visits for the Reynolds family are limited to two hours, and each becomes a six-and-a-half-hour round trip. Mr Reynolds says: ‘If she has a bad day, it’s not like you can just jump in the car. It has to be a planned journey, you have to make sure other children are picked up from school.

‘Sometimes they ring us and as a parent you obviously go right away, but it’s worrying because you know you can’t get there for at least an hour and a half. It’s a massive strain on what is already a big strain for our family. It’s horrible.’

One of the tragic truisms when it comes to OOA placements is that these are generally quite lengthy stays.

The latest data, again covering January 2023, suggests 46 per cent of OOA placements lasted for more than 30 nights – and 10 per cent were more than 90 nights. Comparative data from when the target was set is not available but lengths of stay have increased since March 2021, the elimination target date.

While these placements have a major effect on patients and families, they are also expensive for the NHS.

The vast majority of inappropriate OOA placements – 96 per cent at last count – are sent to private providers. Two firms in particular, Priory Group and Cygnet Health Care, took a combined 76 per cent of the private placements across 38 hospitals in January 2023.

The total cost of inappropriate OOA placement beds was £10.5m during that month – more than double the £4.8m in November 2016, the first full month of data available after Mr Hunt made his pledge.

Consultant psychiatrist Phil De Warren-Penny says: ‘It’s great for the Government to come out with diktats but realistically it needs funding not just in terms of staffing but real estate.’

Dr Eldred adds: ‘You’re throwing good money after bad. And, from a philosophical point of view, I struggle with the idea that taxpayers’ money is essentially going into the pockets of an organisation … that an organisation with shareholders should be profiting from the NHS’s failure to keep internal capacity.’

Nottinghamshire GP Marcus Bicknell, who specialises in addiction, mental health and forensic medicine, adds: ‘It’s a cop-out. The whole thing is a fiasco – we’re basically robbing Peter to pay Paul.’

Dr De Warren-Penny worked for the NHS in Devon until moving to the private sector around a year ago. He says in Devon his organisation had a plan to build new wards but the project would have taken five to seven years owing to procurement rules, planning permission and building work – and that is if it had been given approval for capital funding, which it wasn’t.

Dr De Warren-Penny’s hospital has an arrangement where the NHS directly commissions 15 to 20 beds to reduce the need to send its patients so far away from home. This is the best pragmatic solution to the state the NHS has been left in owing to historic underfunding, he says.

‘It would be lovely for money to rain down from the Government on NHS trusts and the opportunity for new facilities to be built.

‘But if we think about the fundamental principles of the NHS being around care occurring in a timely fashion that is free at the point of access, then my sense is that both things are met and, actually, wouldn’t be met at the moment without this provision.’

The most obvious driver of the use of OOA placements is a lack of mental health beds in England.

The extent to which overnight bed numbers have fallen varies across different settings. Learning disability and mental illness beds have seen reductions of 69 per cent and 23 per cent respectively since 2010-11, for example.

In 2019, the Royal College of Psychiatrists commissioned an independent report which estimated more than 1,000 inpatient beds are required – just to return provision to ‘acceptable levels’.

The BMA is urging the Government to expand the number of inpatient mental health beds in England so that NHS England can finally meet the missed target to eliminate inappropriate OOA mental health placements.

The association is also supporting the Royal College of Psychiatrists’ recommendation that all new integrated care partnerships conduct service capacity assessments and target investment towards services driving inappropriate OOA placements locally.

Dr Molodynski, who is also mental health lead for the BMA consultants committee, says: ‘There will always be people, across all types of medicine, who need to go somewhere away from home for particularly specialised treatment – people with very unusual conditions or very specific needs.

‘And there will be times when local systems are under particular pressure because we can’t all have 300 spare beds.

‘But this situation is chronic. This situation is endemic. It’s nothing like either of those two scenarios. We have become desperately reliant on shipping patients a long way from home into private sector beds and we are now trapped in this way of doing things.

‘We need radical action to break this cycle.’ 

Additional work by BMA senior policy adviser Olivia Clark and policy advice and research officer Claire Chivers

*Editor’s note: We took the decision to give pseudonyms to the people we have named Eve Reynolds, Joe Reynolds and Deborah Park