Written evidence submitted by Alpha Hospitals Ltd (CMH0068)

Executive Summary

• Alpha Hospitals have been providing psychiatric intensive care services to young people for a decade. During this period we have gained an immense knowledge of the market, knowledge of the needs of the patients and knowledge of the needs of the NHS.
• The demand for psychiatric intensive care services has grown. This is fuelled by young people not coming into hospital as quickly as they used to and therefore, the level of acuity on admission is far higher than it was even five years ago. Earlier admission to hospital would reduce length of stay and would promote better outcomes.
• The demand for services at the higher end of the care pathway has grown. We are seeing an increased patient group needing to be referred from psychiatric intensive care units to low secure or medium secure care.
• Length of stay has increased in the last 10 years. This is reflective of the higher acuity and young people being admitted at a much later stage of their crisis.
• The highly specialised nature of CAMHS Tier 4 services means there are high barriers to entry. Buildings are best when purpose built for the client group. Expert staff are a scarce resource. The massing of experts in regional hubs can provide the best way of delivering these complex services with the right expertise that can ensure good outcomes.
• Given the level of demand for safe, appropriate beds for young people, Alpha Hospitals is surprised that the NHS is unable to commission 15 psychiatric intensive care beds and 12 low secure beds which are vacant and fully staffed in a large City location where there is no other local provision. These beds were developed prior to the In Year Service Development Policy in July 2013 but the moratorium on new capacity is preventing young people from accessing the care that they need. Young people could be treated in these beds and not placed in inappropriate settings such as adult wards and police stations.
• We believe that funding should follow the patient and be led by their needs. The current arrangement of funding being allocated to providers with a history of service provision is not a guarantee of quality or efficient or effective services. By reverting to commissioning on a spot purchase basis, the NHS could control costs and commission the most appropriate placement for the young person at that point in time. Those providers who do not meet the quality thresholds would fall away leaving the NHS with the best of the best in terms of care.
• Current capacity issues within Tier 4 CAMHS means that patients who need to move up the care pathway cannot do so without substantial delay. The level of low secure beds available is inadequate.
• Current capacity issues with Tier 1-3 CAMHS means that discharges from hospital are delayed and both health and local authority provision is not sufficient to meet the needs of the patient group within an appropriate time frame. Young people are spending unnecessary amounts of time in hospital after they are ready for discharge.

1. Introduction to the organisation

1. Alpha Hospitals is one of the UK’s leading providers of psychiatric intensive care; low and medium secure mental health care services. The company was established in 2002, with purpose built, state of the art hospitals in Bury in Greater Manchester, Sheffield in South Yorkshire and Woking in Surrey, providing an extensive range of specialist psychiatric care for people with mental health conditions and learning difficulties. The specialist mental health services, which are gender specific, include personality disorders, mental illness, rehabilitation, Deaf, and CAMHS Tier 4.

2. Alpha Hospitals works in partnership with the NHS and is committed to providing outstanding levels of service to patients and stakeholders, that is flexible and needs led based on the individual’s requirements.

3. Alpha Hospitals have been providing psychiatric intensive care services for male and female young people in gender specific units for the past decade. The Tier 4 services are for young people who are high risk, have dual diagnosis or complex problems, who need intensive care.

4. We believe that every young person with a mental illness has the ability to recover. Our service for young people aims to provide high quality assessment, treatment and rehabilitation in partnership with the NHS. The service provides a therapeutic milieu that supports young people, working together and with a highly experienced multidisciplinary team to make sense of what is happening to them. Young people are supported in sharing their experiences and developing strategies for peer support and reconciliation with their friends and family.

5. When a young person is in crisis, help is needed straight away, especially at night and at weekends. Our services provide that initial place of safety for immediate stabilisation followed by progression to our intensive therapeutic programme before moving down the care pathway or returning to the community.
6. We provide care for complex cases who experience comorbid mental health disorders including challenging behaviour. Our care pathway provides the low stimulus environment required on admission combined with more intensive therapeutic programmes and education required at the next stage of treatment which helps to reduce the length of stay.

7. All of our adolescent units have been built to a high standard with this challenging patient group in mind. Hospitals are modern and bright and tailored to be a welcoming environment for young people. The environmental design places significant emphasis on safety, therapy, welfare and education. We meet best practice guidance set out by the Department of Health guidelines and based on the recommendations of the Quality Network for Inpatient CAMHS (QNIC).

8. Each individual unit provides a range of recreational space as well as private bedrooms with full ensuite facilities. An education service is fully integrated. There is access to sports grounds, gardens, gyms and the many facilities in the local communities. We believe these specialist CAMHS services should be located in the heart of the community with easy access for staff, visitors and patients by car, train and bus/tram.

9. Alpha Hospitals provide 98 beds for young people.  Eighty six beds care for male and female young people in psychiatric intensive care services and 12 beds are dedicated to low secure services for female young people. At the time of writing this report only 71 beds are commissioned by NHS England. Twenty seven specialist psychiatric intensive care and low secure beds remain vacant in a purpose built environment and are blocked to referrers because of the moratorium on new services. The Tier 4 CAMHS within the Alpha Hospitals group are as follows:

Alpha Hospital Bury, Bury, Greater Manchester

CAMHS Tier 4 Psychiatric Intensive Care Beds:                            42

Young male beds: 12

Young female beds: 30

These services operate at capacity and are fully commissioned by NHS England.

Alpha Hospital Sheffield, Sheffield City Centre, Yorkshire

CAMHS Tier 4 Psychiatric Intensive Care Beds:                            15 (female only)

Low Secure Beds:                                                                       12 (female only)

These services are fully staffed but empty. This is due to the moratorium on commissioning new services. The strategic plan to develop these beds was in response to high levels of need. Work on the development of the service commenced in September 2012. NHS England issued its policy on the moratorium in July 2013 and applied it retrospectively.

Alpha Hospital Woking, Surrey

CAMHS Tier 4 Psychiatric Intensive Care Beds:                            29

Young male beds: 10

Young female beds: 19

These services operate at capacity and are fully commissioned by NHS England.

2. Service provision and practical experiences

1. Alpha Hospitals have been providing CAMHS Tier 4 services for 10 years. The first service in Woking, Surrey was set up to meet the needs of the local population. The service was developed in partnership with the local NHS Trust. It quickly became apparent that demand for specialist CAMHS beds was a national issue. Referrals flowed in from across the country. Within a matter of months the service was operating at maximum occupancy with waiting lists.
2. The high level of demand and the placement of patients out of area led Alpha Hospitals to discuss the need for a service in the North West of England. This was welcomed by commissioners and this service was set up in November 2011. The level of demand to this service was extraordinary and the service was full with a waiting list within six months.

3. Operating a service for complex young people is extremely challenging. Buildings must be fit for purpose as they are robustly challenged by the client group.

4. The staffing of the service is highly complex. Expertise in the field is a scarce resource. Specialist training is an ongoing requirement for all staff. Supervision needs for staff are high because of the challenging nature of the service. 

5. The cost of provision of Tier 4 psychiatric intensive care services are extremely high. Scare resources in staffing mean that the cost of recruiting and employing staff is greater than in other psychiatric services. The staffing levels dictated by the Quality Network mean that staffing costs are high. The NHS are squeezing bed prices to drive more efficiency. In order to meet these cost pressures, providers need economies of scale to make the services viable to run. A fifteen bed stand- alone Tier 4 service is not viable. A 40 bed hospital split into wards of not more than 12 beds is viable.

6. The cost of massing the expertise needed to treat this complex patient group means that the provision of small, local Tier 4 services would not be financially viable to an independent sector operator, therefore local services for local people may not be an affordable option where specialist care is concerned.

7. In the decade that Alpha Hospitals have provided psychiatric intensive care services for young people we have seen the profile of the patient change. The level of acuity on admission has increased sharply along with the level of violence and aggression. This is a direct result of young people waiting longer before they are referred to an intense inpatient setting. Complex patients can be managed very successfully in the community and through Tier 3 services but patients are arriving in our psychiatric intensive care units in extreme crisis. Admission to our service at an earlier part of the process would prevent the young person from deteriorating to such an extent and reduce length of stay.

8. Our services have young people who wait protracted periods of time to move down the care pathway. Often, local services are fearful of the young person moving back to the community because of the extreme crisis under which they were originally referred to hospital. Local services are stretched and there is often no appropriate provision for the young people to move to. We have experienced young people waiting up to two years for an appropriate placement after they have recovered. Delayed discharges are measured each Quarter by NHS England. Unfortunately the lack of community services means that at the current time we are not able to improve on this indicator.

9. Often extremely complex patients are referred to our psychiatric intensive care services. Following admission and assessment patients can be identified as needing access to a higher level of care i.e. low secure care or medium secure care. Beds within these services are rare. We have waited up to four weeks to have a patient assessed for secure services. Often the wait for a bed, once approved, can also be many weeks. During this period, the patient concerned has to be managed in an inappropriate setting. Managing a patient who needs a higher level of security also has an impact on the rest of the ward and can often trigger the destabilisation of other patients. It is imperative that once patients are identified as needing to move up the care pathway that an appropriate bed, in a reasonable timeframe can be found.

10. Young people can often become ‘revolving door’ patients. They are admitted to hospital, they recover and then on discharge, without as much support as they need, they quickly deteriorate and become a re-admission.

11. The challenges of managing patients as described above also creates complexities for the regulator and for NHS England as additional monitoring is put in place to ensure the safeguards of the patient.

12. The experience and knowledge of the regulator can also be a factor affecting the ability to deliver these complex and challenging services; in our experience, NHS England has invested heavily in understanding these patients and the services they are referred to. A similar investment exercise undertaken by the regulator would have significant benefits to the ultimate delivery of the services.

3. Access and availability of services

1. Psychiatric intensive care services provide an emergency service 365 days a year, 24 hours a day. We are able to facilitate the admission of a patient within an hour subject to the patient meeting the admission criteria, a discussion between the referring team (at senior clinician level) and the hospital team and funding being in place. Our aim is to provide that place of safety where a young person can begin the journey of recovery. Young people are transferred from police cells, 136 Suites, A&E, the community and other acute units.

2. There are factors that can prevent admissions. Acuity on the ward may mean that it is not appropriate to admit a new patient. This can block beds, reducing the capacity in the market and placing a strain on referrers searching for an appropriate place of safety.

3. Bed blocking by young people who are well and need to discharge but cannot due to a lack of appropriate service to go to reduces available beds in the market.

4. Alpha Hospitals is often asked to take exceptional cases that cannot be managed in other settings. These cases are usually where the young person has attention deficit hyperactivity disorder with borderline learning disability. These patients are often refused by other hospitals. Expertise for young people with these disorders would only be available in a regional centre of a larger provider such as Alpha Hospitals or St Andrews. These cases require bespoke, personalised care packages which often mean only one or two patients on a ward.

5. In order to manage acuity and delayed discharges, services need to operate enough beds to facilitate an admission to more than one ward. Expansion of beds commissioned by the NHS would help this but the moratorium on new beds means that providers cannot respond to market need making accessibility easier for referrers.

4. Funding and commissioning

1. The structure of NHS England with a single Account Manager and supporting Local Area Teams works extremely well. This is the most cohesive commissioning and management structure that the NHS has had. As an independent sector operator, Alpha Hospitals has found working with NHS England to be hugely supportive. NHS England drives tangible improvements in the quality of care that they commission. They get to know services inside out and work in total partnership with services to drive forward the patient experience and the quality of the service.

2. NHS England introduced an ‘In Year Service Development Policy’ in July 2013 in order to seek NHS approval for new beds. Whilst this was not meant to stifle the innovation and investment being made by the independent sector, NHS England has not authorised any new beds bar marginal increases of one or two beds. Effectively, NHS England has served a notice on the market that prevents operators from doing what they do best which is meeting the needs of the NHS and complimenting services not competing against them. NHS England applied the ‘In Year Service Development Policy’ retrospectively to services already under development prior to the policy coming in. Although the policy requests the submission of a business case to justify any new development, NHS England do not seem able to respond to such business cases. In our experience NHS England appear constrained by an inability to access funds to purchase the additional services needed and thereby ensure that young people are treated in an appropriate setting, in a timely manner and within a reasonable distance from their home.

3. The independent sector recognises that the NHS requires assurance that there is effective management of expenditure and care. However, the sector already works effectively to strict contractual obligations, NHS commissioning mechanisms and case management procedures. We meet clear placement protocols and deliver quality outcome measures set within competitive pricing structures which offer flexibility to the NHS depending on patient need. These factors should assure the NHS that patients are only admitted on a needs basis and that funding should again be allowed to follow the patient and not be predetermined and only site specific.

4. It is our experience that there is a clear need for additional beds. Due to the complex nature of the adolescent patients we care for, most referrals are emergency referrals and there is not the opportunity to place these patients on a waiting list. Similarly, we do not provide acute care where there is available capacity in the NHS. We care for very complex challenging patients (i.e. only detained patients who are very complex with high absconding risks) and our experience is that additional capacity is required. This is evidenced by increasing referrals to in-patient CAMHS.

5. Catchment

1. Alpha Hospitals accepts referrals nationally. The list below details the regions that are regular referrers:

•              London

•              West Midlands

•              East Midlands

•              East of England

•              Gloucestershire

•              Yorkshire & Humber

•              South East Coast

•              North West

•              Channel Islands

•              East Anglia

•              Guernsey

2. Alpha Hospitals has developed services for young people over a number of years. The first site in Woking, Surrey treated a large number of young people from the North West and the opening of services for young people in Bury, Greater Manchester enabled us to offer beds to young people much closer to home. The development of beds for young people in Sheffield was as a result of a decreased need for adult beds in Sheffield and a recognised need that young people from East Midlands and Yorkshire (who were being treated in Surrey and Manchester) needed a more local service. The announcement that adult beds (which were not needed) could be converted into beds for young people with an investment of £1.2m was welcomed by commissioners, however, the Sheffield service sits empty as the moratorium prevents NHS England from purchasing the beds and young people remain in placements far from home.

6. Complexities within Psychiatric Intensive Care Units

1. At the point of admission to a psychiatric intensive care unit all other attempts to care for the young person in a less restrictive environment have failed and an urgent place of safety is needed. Often, once the young person has been an inpatient on the psychiatric intensive care unit for a number of weeks it can become apparent that an even higher level of care is required. This necessitates a referral to the secure estate (low and medium secure services).  A shortage of beds within the secure estate means that young people are often left for weeks and months in a level of care that is not suitable. This also occurs when young people move down the care pathway i.e. into a local authority secure placement.

Under the terms of the contract that Alpha Hospitals works with NHS England we record the number of discharges from adolescent services. This has never moved from a ‘red’ indicator.

7. Quality of Care

1. The monitoring of services by NHS England helps regulate the quality of care and the growth in the market. This should ensure that providers meet high standards. The current system of funding historical providers with a financial envelope rather than funding quality providers means that patients are not accessing those providers with the highest standards of care.

18 March 2014