For years the summer has brought ever grimmer warnings about the crisis in mental heath services, expressed by the annual number of patients who have had to travel 'out-of-area' to receive vital, often life-saving treatment for mental illness which they should be able to receive close to home. Amidst recent reports that funding for mental health will continue to fall - or to be siphoned off by other services - the prognosis for this year's figures was never promising. Indeed, the latest data are damning; in 2016/17, nearly 6000 patients had to be sent away from their local area - hundreds of miles in some cases - to receive treatment for mental illness. This would be unthinkable for people who had suffered a heart attack, broken their arm or needed their appendix removed, but has grown to be a national scandal for mental health patients.
This is by no means a matter of mere inconvenience - the National Confidential Inquiry on Suicide and Homicide by People with Mental Illness identified a link between out-of-area placements and heightened risk of suicide back in 2015, and called for a ban. I called for the same when I co-authored the final report of the independent Commission into Acute Adult Psychiatric Care in 2016, suggesting that October 2017 should be the cut-off date for Trusts to have gotten their houses in order. In response, the government committed to eliminate them by 2020/21. You would therefore expect the numbers to be decreasing, but instead they have inexorably risen; the most recent figures show a fivefold increase since 2011/12 and an increase of 40% in the past two years alone.
The causes are complex. Certainly, it's plain that in some areas there are simply too few inpatient beds. Data show that although the underlying incidence of mental illness has stayed roughly stable over recent years, the number of mental illness inpatient beds is at an all-time low - so perhaps it's no surprise that the number of people having to be sent out-of-area due to bed shortages is at this all-time high. However, this analysis doesn't tell the whole story. When the Commission conducted research into the underlying causes of the rise in out-of-area treatments, we found that the problem lay more in system-wide failings. Over half of the doctors working in adult mental health inpatient wards who responded to our data-gathering exercise said that there were either enough beds in their local area, or that there would be if changes were made to other services such as home treatment and crisis teams. We found that almost one in six patients who had been admitted to an adult mental health ward could have been treated in an alternative setting, and that another one in six were well enough to be discharged, but could not be because of a lack of community resources (methodological note - some people may have fallen into both categories). Put simply, this demonstrates that it's often more complicated than just a shortage of beds.
The scandal of out-of-area treatment is by no means insurmountable, although there is no panacea. As set out in the Commission's report, the answer lies in analysing services to see where the bottlenecks are, developing better data collection systems, improving staff training and morale, encouraging better local working, making more supported housing available, introducing quality improvement methodologies and setting new, challenging targets - such as a four-hour wait in psychiatric emergencies for patients to be either admitted to a inpatient unit or for home-based treatment to commence. This last suggestion is deliberately modelled on the four-hour wait for Accident and Emergency, reflecting the view that the principle underpinning mental healthcare should be to treat it and physical healthcare with parity of esteem. Unfortunately, despite the historical success of the A&E target, the government did not take the bold step of adopting this recommendation. In some places, some pump-prime funding may be required - but given that out-of-area care is more expensive than local care, this should be easily recouped.
More bad tidings seem inevitable in the short term, as neither the Commission's suggested deadline of ending out-of-area treatments by October 2017 nor the government's own 2020/21 target seem likely to be achieved. This is demoralising for patients, carers and professionals alike; glad tidings have been in far too short supply for mental healthcare over recent years. Some comfort can be drawn - and inspiration taken - from the services and professionals who are working with patients and carers to provide innovative, patient-centred care close to home which avoids any out-of-area care (and saves millions) by preventing unnecessary admissions. But if these annual figures haven't dropped precipitously by next summer, then patients and carers deserve to know why not.