Sectioned for a bed: results of our RCPsych survey of trainee psychiatrists

Some aspects of the crisis in mental health care, like the 1,700 bed closures and 101% ward occupancy rates, have been relatively easy to estimate. But worrying practices associated with the strain on resources, like patients being sent home in the absence of a bed or being sectioned to secure one, have been far harder to quantify – until now.

The Royal College of Psychiatrists Trainees Committee has surveyed all junior doctors working in psychiatry in the UK for their experiences over the last 6 months. These doctors are fully exposed to the problems, having an unrivalled view of care from 9am to 5pm and often making decisions about admitting or sectioning patients themselves when consultants are at home in the evenings and at weekends.

576 such doctors responded, and what they told us was deeply concerning.

Over 70% had experienced difficulty finding an appropriate bed for a patient. In child and adolescent services (CAMHS), that number was 83%. Sadly these findings weren’t unexpected, but the rates of various practices associated with the scarcity of beds certainly were.

A shocking 37% told us that a colleague’s decision to section a patient under the Mental Health Act had been influenced by the likelihood of finding a bed – perhaps that by doing so it would legally force the provision of a potentially otherwise unavailable bed. 18% were even willing to tell us that their own decisions had been influenced in such a way. A Health Select Committee report published to widespread concern last summer suggested that patients had been deprived of their liberty to secure a bed in isolated cases, but the true rate seems to be far greater.

Doctors usually use the Mental Health Act as a last resort for patients who desperately need hospital care but are so unwell that they refuse. Now they are presumably beginning to use it increasingly often for patients who aren’t actively refusing an admission, because it’s their last remaining option to make sure very unwell people get the care they need. And it’s no wonder they have to do so, when 24% reported that a bed manager had told them that beds were closed to all patients except those under section. Again, a policy of desperation in the face of pitifully limited resources.

Even if a bed is somehow found, it could be absurdly far away. 80% of respondents had been forced to send a patient outside the boundaries of their trust, with over a quarter sending a patient over 100 miles away. In CAMHS, this was a heart breaking 37%. Unsurprisingly, such transfers were reported to be detrimental to care. Dragging a mentally exhausted, fragile and often acutely distressed person away from their families is not a form of care I recognise – especially if that person is a child.

As an alternative to being exiled hundreds of miles, three out of ten doctors had seen a patient admitted to a ward but without a bed, presumably leaving them to sleep on a sofa. One in five reported that they’d admitted people to beds belonging to patients on periods of trial leave – at least giving a temporary fix. But when the original owner of the bed comes back, as they often do, out comes the sofa again.

After a decade in medicine the only circumstances in which I have known patients to be admitted to hospital without an official bed have been whilst volunteering in the developing world and in UK mental health.

Still, a sofa may be better than sending a critically ill patient home because no bed can be found. An alarming 28% admitted to doing that. The rate in CAMHS was even higher at 37%. If just one paediatrician reported that they’d sent a sick child with asthma or appendicitis home simply because there wasn’t a bed, the reaction would be swift and scathing. But if the child has a mental health problem, their suffering appears not to warrant the same level of concern.

It would be easy to conclude that the answer to this nightmare is additional beds. That would certainly help, as would providing emergency support to forestall the plans to close more beds in some places, but the cause of this crisis is more pervasive. A chronic institutional bias against mental health has suffocated the funding of our speciality in every area. Community teams have seen their funding plateau in the face of a 13% increase in referrals despite the fact that a recent report suggested that for every £1 invested in early intervention we could save £15 in later hospital admission costs.

As reassuring as it is to read the recent Closing the Gap and Crisis Care Concordat policies, only a clear, urgent and substantial pledge of extra funding will convince mental health professionals that things are about to get any better. Despite the heartening rhetoric, such funding has not been forthcoming.

In fact, following February’s NHS England announcement that mental health services would ironically be subject to greater tariff cuts than our counterparts in acute services, Professor Dame Sue Bailey suggested that the frankly dangerous levels of under-resourcing might lead us to become the next Mid Staffs.

Based on these stats, I would go further. What will it take for us to admit that we’re already there?

The full results of the survey can be found here.
The results of the survey specific to CAMHS can be found here.


About Alex Langford
I am a psychiatrist (now an SpR) based in Oxford after 3 years working in South East London. Before I went into psychiatry, I used to be a general medical doctor, and I also have a BSc in psychology. I'm particularly interested in improving the public face of psychiatry, evidence based medicine, teaching and patient rights. Don't mention cricket unless you've got the next fortnight free to discuss it.

23 Responses to Sectioned for a bed: results of our RCPsych survey of trainee psychiatrists

  1. Pingback: Sectioned for a bed: results of our RCPsych survey of trainee psychiatrists

  2. Rory says:

    Alex, this is yet another impressive piece of dedicated work and writing. I’m delighted to see it as front page news on BBC website. Well done!

  3. Jean Davison says:

    I remember this bed problem from ten years ago when I worked for the NHS in admin. There was one instance where a psychiatrist felt his patient needed to be sectioned but there was no bed available and the outcome was that the patient was not sectioned!

    How very different things were 40 years ago when I was a patient. Beds always seemed available and people easily admitted (often informally) for all sorts of spurious reasons.

    I know I’ve nothing useful to contribute to a discussion on how to solve the serious problem of bed shortage, but hope you don’t mind me just adding these thoughts here.

  4. Great article, still learning the UK system but we are having similar problems in The States. One solution is one area has a 9 bed short-term unit (3-5 days). This is mainly intended for patients not really linked to treatment, get the ball rolling and get them out. It is catching a lot of people in crisis without outpatient treatment and reducing the chances of them coming back.
    As a children’s case manager it is a whole other world with finding them a bed. There is a lot of shortages and ER’s “cure” them overnight. There is a community based crisis team, which catches a lot of unessessary admissions. Despite this it is often a struggle. Sometimes families just need a break and this is where a short-term 4-7 day model could really help. More framing as a break to reduce risk, connect with services, and supporting parents with follow up.

  5. SevenMillionOfUs says:

    This is so bad. I can hardly believe the figures. I can only respond from my experience as a carer because this impacts on us all.

    When my son was acutely ill last year, he was not admitted and I was pleased he didn’t have to be in hospital, as was he, but it took its toll. 4 months of acute psychosis before the positive symptoms subsided was tougher than anything I’ve known. At the time I thought maybe it was because he wasn’t thought to be too unwell (what did I know?) now I reckon he was very unwell and it was a resources decision. I was often in despair trying to do alone what a whole ward of MH professionals would have done, with zero experience, virtually no support for myself, and of course the distress of caring for someone you love is a different thing altogether to looking after a patient as a professional.

    Once I rang the MH team at a complete loss,frightened, exhausted, and with no idea how to deal with a particular crisis, and was told ‘ Do what you think is best’ –
    I had to fight for answers when I was at my lowest ebb. I was later told off for bothering the MH team too frequently.
    Care in the Community- ha.

    And I am one of the lucky ones…. I was able to take sick leave from my job, I had good friends, I am pretty assertive and resourceful, my son was lucky that he had a roof over his head and a mum, one who cared. I know not everyone has these supports. I know there are people struggling with far worse for far longer.

    And still I don’t know how we survived. And I could write a whole other story about the cost to my own mental health. And I’d do it again because I love him, and maybe that’s how the country knows it doesn’t need to change anything.

    But writing individual sob stories won’t change anything. It needs a political response.

    “Research conducted by Leeds University in 2007 showed that carers now save the state £87 billion a year.” To put that sum into context, it’s more than the entire annual NHS budget for that year.

    • gill williamson says:

      my husband is currentlly over 300 miles from home as there are no psychiatric beds available in cornwall will this improve his mental health being isolated from his family and does this contravene his human rights

  6. elvis jones says:

    I don’t really find myself very enthused by the latest crisis. Even with a bed, why be so keen to say goodbye to being a human being and becoming drugged. It will.take the pain away but it also takes your individuality away too….maybe for decades. If you have a life story then it may get lost. Sometimes I think that mental health becomes a science like marxism in that it is a system and it knows all the answers, and that it is an enemy of freedom. I might be being paranoid of course…..Marxism worshipped the state, what do psychiatrists worship (if anything, generalisation/all psychiatrists the same counterpoint accepted)? And more to the point, do I really want to be part of that? Will I even know what is going to happen to me? In my experience reassurances count for nothing. Sorry.

  7. Pingback: Is sectioning for a bed a violation of human rights? | Mental Health and Mental Capacity Law

  8. elvis jones says:

    Everybody talks about making mental health services better, and how there should be higher standards and more compassion and the rest very noisily but very few if any would have a clue how to do it. I don’t think the problem is lack of money. It is giving responsibility to people who do not have moral backbone and courage. It is far too easy to give false information because there are no personal consequences. In my area I have extensive proof of malpractice involving several Directors, a nurse, and a Chief Executive.

  9. elvis jones says:

    Maybe it’s time to release those documents into the public domain. I will.give them wind of this and see how they react.

  10. elvis jones says:

    Well it’s very interesting. One person is a staff governor who has been warned about this before. I wonder why nothing was done then. Looks like these free agents are maybe not so free. How long will she ‘forget’ to look at her comments? Will she be thinking of not being found responsible for anything, or will she be thinking, I would like to see justice done? Hmmmm. Big problem isn’t it? I know I will due my duty and report it, and yes I may be lying to myself and I can always say I hate myself, but then that’s a good disguise. Go on, run to your Director. It can be a lonely world. I expect her brain has mixed messages.

  11. elvis jones says:

    The usual trivialisation of severe abuse. The individuals involved were members of Dorset Healthcare. They were Paul Sly, Brian Goodrum and Tim ARCHER. All were found to have told serious lies over a period of years regarding the care of an extremely vulnerable person, who has had to have emergency care as a result of the abuse. Jodi Brown was made aware and did nothing.
    The lies that they told are matters of written fact and are acknowledged by the Chief Executive Paul Sly under direction from the parliamentary ombudsmen.
    Jodi Browns site has professional contact with Paul Sly despite telling everyone online that it is safe to raise concerns. I am puzzled by the logic here: do you want it to be safe to raise concerns, or do you just want people to think it is safe, but reaLly carry on as normal?
    If you are serious about safeguarding patients, then how do you think it appears to that vulnerable person when you sidle up publically to a documented abuser? My gut reaction is that she doesn’t care, she knows more than she’s prepared to say. All that from a senior psychotherapist! God help us.
    A psychotherapist must abide by professional code. It is a (badly) regulated profession. If you are unable to act ethically when a safeguarding issue arises, then you must be unsuitable for the profession.
    I’m going to wait for the bullying to start again……..

  12. elvis jones says:

    If you look at Jodi Brown’s Twitter account it continually pumps out innane quotes. Anything, like this, of any substance and she is completely stumped. Going back to the bed shortage problem, which is a real crisis, is it any wonder when NHS employees are being paid millions to saturate the internet with rubbish?

  13. elvis jones says:

    Professor Susan Clarke, who also runs a DBT training company, claimed that the proven abuse by a DBT therapist who is also a member of Dorset Healthcare, had nothing to do with her, in an email. Now, does that sound like safeguarding to you? That is the typical behaviour of an abuser, who tries to trivialize a very serious example of professional malpractice documented with the ombudsmen.
    Her behaviour invites the question: Which is the most important? The client, her relationship with Dorset Healthcare and the way that power is negotiated, or her business?
    Looking at the evidence, only the last two possibilities fit the evidence.
    It is astonishing that someone of that level could be so naive as to stake their professional credibility, their scientific credibility, their place at university on a daft email.
    Now she referred me back to Deborah Howard who ‘ is looking into it.’ Well, what have you found? Slippery and weasel worded. That’s prof Clarke. Unreliable, dishonest, cowardly.

  14. elvis jones says:

    I shall let them take their revenge. And I shall say nothing. Give your enemies a drink of water……If you want to harm me, go ahead. With all this power, do what you want. Do you know what you want? No. Well X, it’s like it was before…….take it. No one’s going to stop you. Read out your true statement. You will see the power of forgiveness.

  15. elvis jones says:

    I am absolutely stunned. Tim Archer is working for the NHS in Somerset. With his record? It’s beyond belief.

  16. elvis jones says:

    Why and how to save the NHS

    Alex Langford is good enough to listen to people so I am going to give him something very special. A practical way to solve some of the major problems in the NHS has faced.
    At the moment the Chief Executives rely on information given to them by Directors about the grass roots. In a sense they are blind, making decisions based on information that can get corrupted up the management chain from the initial incident.
    To be able to test, monitor and evaluate staff and management chains in response to a safeguarding incident or any other serious incident then why not create one?
    The chief executive would create a fictitious incident at grass roots level whilst everyone.else would be blind. As he/she has certain knowledge of the nature of the incident, then she can see how the incident is reported up the chain, how long it takes, and if the report that goes on her desk (assuming it ever gets there) is any good.
    Why wait until a real incident occurs to find out if you are any good as an organisation at handling problems.
    The Chief Executive can then debrief her staff and see how they have done, what needs to be changed, etc.
    Presently, staff panic and try and bury the problem, making a catalogue of errors. With training they could be very effective. This would save the NHS millions and provide enough beds for seriously ill people.
    It is scientific and is used by organisations such as the police, military, MI5 etc. It could save hundreds of lives and be quite sophisticated.

    • Honest ex employee says:

      Elvis can you contact me please ….. I am in comms with MP and was victimised under these managers ….PO is next step for me

    • Honest ex employee says:

      Please contact me I am I comms with MP and just taking evidence to PO ….

      • elvis jones says:

        With a Bournemouth university email? Who are you and why are you so interested?

      • Ex employee says:

        The report into my whistleblowing did not address serious concerns and a crime occurred….I am not an employee I was bullied out for speaking up. I have evidence of suicides occurring in a service with NO risk policy and none of the regulators will look at it. For me now it is police and press, not necessarily in that order …am taking advice. Do contact me.

  17. Pingback: Dear Psychiatrists, The Mental Health Act was not drafted for your convenience… | Mental Health and Mental Capacity Law

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