It’s not about beds: why the debate around NHS vs private sector capacity in mental health services needs to change
Another week, another story about mental health in the media: this time a long-read piece in Monday’s Financial Times about ‘the costly, controversial outsourcing of NHS mental health services spending on out of area beds.’ The article states that the practice of NHS patients being sent to private inpatient psychiatric facilities has reached a record high, which is not only costly but detrimental to patients who are often sent far away from home. It also hints at the idea that private providers may be financially incentivised to keep people in hospital longer, again impacting an already stretched NHS.
This isn’t the first time we’ve heard about bed shortages in mental health services, and unfortunately it won’t be the last. When I was a commissioner of mental health services over a decade ago, demand was lower and funding was more of a challenge, but there was still an issue of placing people out of area and often for significant lengths of stay, at great cost. Things have undoubtedly changed (for the worse) since then, highlighted by improved data, but the challenge of how to treat people with mental illness still endures, and the idea that it is all about beds is a fallacy. It is not as simple as creating more inpatient capacity within the NHS and reducing reliance on the private sector, in fact, I would argue that the focus of the conversation should not be on beds at all.
The recent surge in demand for inpatient services reflects a system which still focuses on sickness instead of wellness, waiting until people become critical before it intervenes. Rather than incentivising prevention, both NHS and private providers get paid based on how many patients they treat, so the focus is always on how we can create capacity for more people rather than how to support them to be their most independent and living life to the fullest. As a result, there is an enduring argument in the sector that we just need more capacity – more beds, more staff – to treat the tsunami of mental illness coming our way. But here's a novel idea: what if we started paying for empty beds rather than full ones?
Early identification and treatment of mental illness, with skilled care, supported by the best technology available in the community, can actually reduce the need for hospitalisation by preventing people from ever becoming that unwell. Paradoxically, if healthcare systems were incentivised around prevention and early intervention rather than focusing resources on specialised inpatient services, then we might actually see capacity in those services begin to ease.
Traditional core service models in mental health, which continue to be staffed and commissioned across the NHS, were developed in the 80s and 90s. Dealing with the perceived demands of the time, these models had beds as a key requirement, therefore there is a natural assumption that if demand increases so must inpatient capacity. However, we now know that early identification and treatment of mental illness, with skilled care available in the community, can reduce the need for hospitalisation by preventing people from becoming that unwell.
The evolution of mental health services needs to be focused on outcomes and not activity. This means we need to work with patients and families to look at what outcomes should be achieved, rather than thinking we know best and that inpatient services are the answer. Rather than being seen as the enemy, private sector partnerships will be critical in achieving this outcomes-based model, and there are opportunities to focus on place, system and regional level, looking at the whole pathway from prevention through to inpatient services.
These partnerships could exploit the strengths of the private sector providers who can deploy capital more quickly and easily if there was long term return on investment, and where the NHS could utilise its brand for providing high quality care. Technology will be a crucial part of this, with novel solutions able to provide more accurate insight on capacity requirements, as well as alleviating pressure upstream in the patient journey.
One such example of the use of technology and private sector partnership to tackle challenges in mental health services, is Hertfordshire partnership NHS Foundation Trust’s use of Censeo, a web-based tool for mental health triage and assessment. Hertfordshire’s Single Point of Access (SPA) in Secondary Mental Health Services went live with Censeo across their entire region last year, and they now use Censeo to triage and predict pathways for all routine (non-crisis) adult mental health conditions.
The results so far are promising: Censeo saved significant time, approximately 50% of triage and assessment time, based on 481 assessments completed between September and October 2023, and further product improvements have been identified to increase this to 7.5 hours in Q1 2024. Freeing up clinician time at the assessment stage is crucial, as this capacity can be redistributed to treat patients at various stages in their journey. I would argue that it is this type of capacity we should be focusing on, rather than looking at beds. Furthermore, the clinicians and patients using Censeo are satisfied with their experience, with 81% of clinicians agreeing Censeo was useful and improved quality of care, and 75% of patients feeling positively about Censeo. This is just one example of how novel technology and private sector input can make a real difference in this field.
I don’t think we will see an end to the NHS vs private sector bed debate any time soon, but hopefully there is a growing appetite for alternative solutions, and this is certainly something we are seeing with the NHS trusts we are speaking with. Ultimately, we could build and buy many different beds with either an NHS or private sector badge on them, but if people’s basic needs are not being met, all we will do is treat more patients for mental illness in different settings. Instead, we need to explore more novel approaches that put the power in the hands of people who make their own decisions about their lives and health and putting them in control at the assessment stage must be the first step in this.
