A report from the Health Services Safety Investigations Body identifies the urgent and ongoing issues facing mental health inpatient care.
The mental health crisis is too often talked about but little acted on. As Healthcare Today reported on in May, the average time a person in a mental health crisis spent in A&E last year was an hour more than in 2023.
It is recognised as such an issue in Britain, that international healthcare group Bupa recently said that is to open 70 mental health centres across the UK in response to increasing demand for workplace mental health support.
A report from the Health Services Safety Investigations Body (HSSIB) has identified key risks across multiple areas that continue to affect the safety of mental health inpatient care. These areas include safety, investigation and learning culture, system integration and accountability, the physical health of patients in mental health inpatient settings, caring for people in the community, staffing and resourcing, digital support for safe and therapeutic care, suicide risk and safety assessment.
“This report shines a light once again on the urgent and ongoing issues facing mental health inpatient care and the reoccurring harm that comes with those issues,” said Craig Hadley, senior safety investigator at HSSIB.
“Too often, we see well-intentioned recommendations fall through the cracks – not because people don’t care, but because systems don’t always support change in a meaningful or sustained way,” he continued.
A lack of action
A central concern running across all themes is that recommendations to support learning for improvement often does not lead to action. The report highlight several reasons for this, including a lack of impact assessments, no clearly identified body responsible for taking forward recommendations, and duplication of similar recommendations across different organisations.
The report on mental health transitions from inpatient children and young people’s services to adult mental health services, highlighted several recommendations made to NHS England but where they could not provide evidence of action being taken in response. Within this report, there is also reference to longstanding recommendations to improve the physical health of people with severe mental illness being delayed, and premature deaths continuing to occur as a result.
“Ensuring patient safety in mental health services means understanding what can be realistically delivered within the pressures of day-to-day care, and aligning that with clear priorities, accountability, and follow-through,” said Hadley.
Too much fragmentation
Another prominent issue highlighted in the report is the fragmentation between health and social care services. The report finds that delivery of mental health care is hindered by poor integration and misaligned objectives between systems. Currently the integration of health and social care relies on relationships, with an expectation and hope that they will work well.
In their absence, a lack of clear accountability can result in poor outcomes for people with mental illness and severe mental illness.
There remains a fear of blame in mental health settings when safety events happen. This contributes to a more defensive culture despite staff actively wanting to learn.
“Our findings call for a more joined-up approach to improvement to ensure that mental health services are safe, effective, and patient-centred,” said Hadley.
