COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY
OFFICIAL REPORT
(Hansard)
Mental Health (Private Hospital) Regulations (Northern Ireland) 2011
21 September 2011
Members present for all or part of the proceedings:
Ms Michelle Gildernew (Chairperson)
Ms Michaela Boyle
Ms Paula Bradley
Mr Mickey Brady
Mr Gordon Dunne
Mr Mark H Durkan
Mrs Pam Lewis
Mr John McCallister
Mr Kieran McCarthy
Witnesses:
| Ms Christine Jendoubi | ) | Department of Health, Social Services and Public Safety |
| Mr Colin McMinn | ) |
The Chairperson:
I welcome Ms Christine Jendoubi, the director of mental health in the Department of Health, Social Services and Public Safety (DHSSPS), and Colin McMinn from the mental health unit. If you give us a presentation on the background and purpose of the legislation, we will then take questions from members.
Ms Christine Jendoubi (Department of Health, Social Services and Public Safety):
Currently, there are no private hospitals in Northern Ireland that offer acute mental health services. There are private hospitals in Northern Ireland, but none of them has mental health services. However, the Priory Group is building a facility at Templepatrick — at risk; it is a private enterprise. It is planned that it will be open within six months to a year.
The Mental Health (Northern Ireland) Order 1986 already provides for private hospitals to be able to treat voluntary patients. If they are to treat detained patients, we need to commence the relevant provisions of the 1986 Order by means of regulations under affirmative resolution procedure. The reason we want to introduce those is that if that hospital opens and provides mental health services for adolescents, and if it has voluntary patients who need to be detained while they are being treated, they would have to be transferred to the adolescent facility at Beechcroft at Forster Green Hospital if we do not introduce the regulations. We would prefer to keep patients in the one place to avoid disruption to their continuity of care.
This set of regulations would allow a private mental health hospital to treat detained patients as well as voluntary patients. We do not have such a hospital at present, but when the Priory Group opens its new facility in Templepatrick next year, we will have.
The Chairperson:
How many people were detained last year? What kind of figures are we talking about?
Ms Jendoubi:
Last year, 12 patients had to be detained at Beechcroft during their treatment. Currently, there is not much demand for adolescent mental health inpatient beds beyond Beechcroft, which has a waiting list of two patients for non-acute care — that is, non-emergency cases. We have not made many extra-contractual referrals. Any referral to the new facility in Templepatrick would be regarded in the same way as referring a patient from Beechcroft to a facility in England. It would be regarded as an extra-contractual referral, and there would be a cost. Trusts that place a patient in Templepatrick would do so only if they could not get a place in a statutory facility.
The Chairperson:
Do adults have access to those acute beds, or does the situation affect only adolescents?
Ms Jendoubi:
The facility that is being opened in Templepatrick is for adolescents aged 12 to 18.
The Chairperson:
Are acute beds available? I know that Dr Bownes, who works in Omagh, has an acute medical facility, but that is only for people who are over 18 years of age. Is that correct?
Ms Jendoubi:
About a dozen hospitals in Northern Ireland have psychiatric beds, but those are for adults. The Beechcroft unit is the only facility that is purely for adolescents.
Mr Colin McMinn (Department of Health, Social Services and Public Safety):
Beechcroft was opened in 2010. It has a total of 33 beds: 18 beds for adolescents and 15 beds for children. Of the 18 beds for adolescents, two are designated as intensive care beds.
The Chairperson:
I do not suppose that you have sought public consultation on the regulations yet because you are seeking approval from us. It would be remiss of me not to ask how professional bodies such as the Royal College of Psychiatrists feel about it. Have such bodies expressed any views?
Ms Jendoubi:
We have not formally sought the views of the Royal College of Psychiatrists. Our advice is that because this is a service improvement, we do not need to put the regulations out for consultation, not least because very small numbers of patients are likely to be affected. We could do so, and we probably will do so before we bring in the regulations.
The Chairperson:
I do not know that I would necessarily agree with that. If we do not have the requisite number of beds here, and young people who are detained in Beechcroft have to be dispatched across the water for treatment, would it not make more sense to provide two or three beds for those patients here? Is it not convenient for the Priory Group to come in and build a private facility now? Should we not be providing that service through the National Health Service rather than tweaking the rules to allow the use of a private facility?
Ms Jendoubi:
The Priory facility is a private one. In the past three years, we have made only 20 extra-statutory referrals across the water.
The Chairperson:
Twenty referrals? Over how many years?
Ms Jendoubi:
Over three years.
The Chairperson:
So the average is about seven a year?
Ms Jendoubi:
Yes.
The Chairperson:
That is a right few for a small place such as this. How will people be referred to the Priory facility? Will that be through their GP or their community practice nurse (CPN)? Who will refer them to Templepatrick?
Ms Jendoubi:
They could be referred by their GP or by their parents, if their parents are prepared to pay the £4,500 a week that it is likely to cost.
Mr Dunne:
A week?
Ms Jendoubi:
They could also be referred by their consultant.
Ms P Bradley:
I declare an interest as a councillor on Newtownabbey Borough Council; the private hospital is in that council’s area. I do not know why you keep saying that it will be in Templepatrick, because that does not come under Newtownabbey Borough Council, yet we gave permission for it. The hospital is on the road to Ballyclare, which falls under Newtownabbey. At the time, when we looked at the proposed facility, there was disagreement from residents. My view is that such a facility is needed in Northern Ireland.
We were lobbied a great deal about the number of patients who were being sent across the water for treatment — for example, anorexia patients. Parents told us that if we had that facility here, they would pay for it. It seemed to us, at the time, that there was a need for it and that there are people who are wiling to pay for this treatment for their children. Now you tell me that there have been 20 patients in three years.
How many beds will there be? I cannot remember.
Mr McMinn:
There will be 30 beds.
The Chairperson:
Surely that is more than we need?
Ms P Bradley:
It has already been passed, and planning permission has been given. It is on the go.
Ms Jendoubi:
The facility is a private enterprise; it is being built by a private company, at risk. It has not been commissioned.
The Chairperson:
It is not a big risk if the Department is preparing to send people to the facility and to pay for that. That is a very comfortable risk.
I am not sure who is driving this. This is the first time that the regulations have come to my attention. I tried to find out what I could, and I am concerned. None of us can be experts on everything, but there are people whom we look to who deal particularly with children and young people — the Children’s Law Centre, for example — and who have experience in dealing with vulnerable adolescents. It seems to me that it would have been fairly crucial to have taken views from groups such as that and medical bodies. That helps the Committee to make decisions based on the consultation and how people feel about it. Without that, we are in a very difficult position.
Paula, had you finished?
Ms P Bradley:
I will maybe come back in again.
Mr McCallister:
Am I correct in saying that these are simply regulations to allow private hospitals to treat detained patients? Are we not, as a health service, probably getting the best of both worlds, in that we have no public resources going into the capital spend? If we need to buy in places, we buy them in; if we do not need to, we do not. Am I correct in saying that this will be regulated to the same standard that we would expect in the National Health Service, if not better?
Ms Jendoubi:
Yes.
Mr McCallister:
You are saying that, over the past three years, roughly six to seven people a year have gone to England. At what cost?
Ms Jendoubi:
Almost £1 million.
Mr McCallister:
Is that for all 20 of them? Or is that £1 million a year?
Mr McMinn:
The average cost of a placement is around £160,000 a year to send somebody across the water to a range of facilities.
Mr McCallister:
For how many weeks would that be? Is that just an approximation?
Mr McMinn:
That is an approximate figure. If someone is referred across the water, a consultant here would agree with the receiving consultant about how long the initial placement would be. That would then be reviewed.
Mr McCallister:
Paula made the point that the facility is needed. The health service or individual trusts will be in a position to buy in that service if there is either a waiting list or a need. The fact that there will be two emergency-type beds could be very positive. At times, we do not always have suitable facilities to handle cases, particularly in emergency situations.
The regulations are probably relatively simple and straightforward to allow trusts to buy in that service if it needs to. I take your point, Chair, that we might want to keep an eye on whether the Department was trying to move towards buying too much from the private sector and not using the facilities that we have. However, at least that would be there if you needed to buy in that extra service.
Ms Jendoubi:
The law as it stands allows private providers to build at risk, which they do, and to treat voluntary patients.
Mr McCallister:
It is just that detained —
Ms Jendoubi:
To do that, they will have to register, just as the Priory Group will have to register with the RQIA. It will be subject to exactly the same inspection regime and standards as statutory providers. The quality of what Priory will provide is pretty well safeguarded. At the minute, any private provider can set up and do that. The regulations simply allow private providers to treat detained patients as well as voluntary patients.
Mr McCallister:
Of course, the same safeguards apply on how you get someone detained —
Mr McMinn:
Absolutely.
Ms Jendoubi:
Yes.
Mr McCallister:
— whether it be through the state, voluntarily, or whatever you wanted to do. I do not have a major concern, because it is a small, technical change to allow that to happen.
Mr Durkan:
Colin, you said that it would cost around £160,000 a year to send someone across to England. Christine, you talked earlier about a figure of £4,500 a week to be treated here at the Priory facility.
Ms Jendoubi:
We made tentative enquiries of the Priory Group about what it would charge, and the figure that it gave us was somewhere in the region of £4,500 a week.
Mr Durkan:
That is more than £200,000 a year, so it would be more expensive than sending someone to England.
Ms Jendoubi:
Possibly.
Ms P Bradley:
It is about more than that.
Mr McCallister:
Do not forget family and support.
Ms P Bradley:
Exactly.
Mr McCallister:
It depends on how long it is for.
Mr McMinn:
To put that £160,000 in context, in 2010-11, there were six referrals of young people to facilities across the water, which, in total, cost around £965,000. There will be variations among those placements.
Mr Durkan:
I support the legislation; I am just haggling.
Mr McCallister:
Just out of interest, what would be the weekly cost of keeping someone in Beechcroft?
Mr McMinn:
The figures are pretty similar: it is around £4,200.
Mr McCallister:
It is a very intensive —
Mr McMinn:
Yes; it is a tier 4 service. When you get to that level of service, the cost is on the staff whom you put around each bed. That is where you get the high cost from.
Mr McCallister:
It is more about the fact that you have the right to buy in that service. As Paula and I said, you would have the family support network in place that would not be there were you to send someone to a completely different part of the country.
Mr McMinn:
Yes.
Mr Brady:
I have a supplementary question on the back of that supplementary. The unit will have 30 beds, but how does that work with the trust? Does it have a contract with Priory to have so many beds? When residential care came in and the trusts took over, they had to contract so many beds a year for older people going in. If there are 30 beds, which are all full with people paying £4,500 a week, what happens if you need to put a patient in there? Are there any contingency plans for that, or do the trusts contract with Priory to have so many beds a year? What are the logistics of that?
Mr McMinn:
It will be entirely spot purchase. There is no commitment from the trusts or the Health and Social Care Board to buy from the facility; that is why it comes at a commercial risk. The process would be that a consultant who is in charge of someone’s care would make a judgement that it would be beneficial to that child or young person to go to the Templepatrick facility. It would be an entirely clinical decision. If all the beds were full in all the facilities in Northern Ireland, consultants would look at options across the water. The trusts currently use some Priory facilities across the water for placements.
The Chairperson:
Your numbers seem to be very out of kilter. Six or seven young people a year are sent across to England. The Priory Group is building a unit that has 30 beds, so the parents of 23 or 24 of those 30 children will be expected to fork out £4,500 a week to keep them there. I worry, because, at the minute, if six or seven young people a year are sectioned and need that level of psychiatric care, they cannot be treated here. However, it does not surprise me. If you were in for the previous evidence session, you will know that — I hate using this word — I am cynical. I suspect that the figures for the young people who are detained or sectioned after the place is built will jump from six or seven to 30, because if there is a private facility here, it will need throughput to make it work.
I make the point that I made at the start: would it not be far more cost-effective to provide the service for adolescents with acute psychiatric need here in existing places? You said already that there are 12 places providing adult beds. Why can our existing services not be tweaked to provide that level of service for young people under the National Health Service here? It would be cost-effective; there would be family support; children and adolescents would be treated here, where they need to be treated; and they would not have to be sent away.
I worry that we have not had the chance to hear from any of the groups that may have an interest in the area and who have concerns about it. Potentially, that might not be the case. Perhaps everybody is happy about it. However, we would still want to hear that from our stakeholders who deal with that area. I am concerned that young people may fall through a loophole that means that they do not get the service and care that they require. I am not convinced, however, that a private facility is the way in which to do it.
Mr McMinn:
If a young person goes into hospital as a voluntary patient, and he or she needs to become a detained patient, those decisions are made by clinicians external to that hospital, thereby removing any self-interest. If and when a young person does become detained, there is an automatic right of appeal to the mental health review tribunal, which is independent. Therefore, there are safeguards in place. The proprietor of the new facility cannot detain more young people in order to generate business. There are legal safeguards to protect young people’s interests.
The Chairperson:
However, that does not get away from the fact that somebody has seen that there is a way to make money out of young people with acute psychiatric needs. OK, it is being done across the water, but we are dealing with a much larger population there. Would it not make more sense to provide this facility for people here under the health service?
I am getting carried away again. Mickey, have you finished?
Mr Brady:
Yes.
The Chairperson:
Kieran has been very patient.
Mr McCarthy:
I am pleased that you are here to address the Committee this afternoon. However, the Committee should hear from the Royal College of Psychiatrists before it gives the OK. I think that you mentioned that earlier.
I have a couple of questions. Do the regulations relate to a patient who is receiving treatment in a private hospital for physical problems and then develops acute psychiatric symptoms that require him or her to be detained, or do they refer to voluntary mental health patients in a private mental health hospital who develop acute psychiatric illness that requires him or her to be detained? Can you describe the procedures that should be followed should a patient need to be detained in a private facility? Finally, can you describe how the private hospital care of mental health patients who are detained will be monitored and regulated?
Ms Jendoubi:
Advance notice of those questions would have been really nice.
The Chairperson:
I am sure, Christine, that you knew you were going to get probing questions from the Committee.
Ms Jendoubi:
It is remembering them. Can I start at the end and work back to the start?
Mr McCarthy:
How would the private hospital care of mental health patients who are detained be monitored and regulated?
Ms Jendoubi:
They would be monitored and regulated in exactly the same way as they would be in a statutory facility.
Mr McCarthy:
In exactly the same way?
Ms Jendoubi:
Exactly the same. It would be done under RQIA.
Mr McCarthy:
Will you describe the procedures that would be followed should a patient require to be detained in a private facility?
Ms Jendoubi:
The procedures for those patients would be exactly the same as for those in a statutory facility. Forms have to be signed by a treating clinician who has seen the patient within the past two days but is not a member of staff of that facility. As Colin described, Priory will need to bring in an independent clinician to assess and sign for that person to be detained.
Mr McCarthy:
Do the regulations relate to patients who are receiving treatment in a private hospital for physical problems and develops acute psychiatric symptoms that require them to be detained, or do they relate to voluntary mental health patients in a private mental health hospital who develop acute psychiatric illness that requires them to be detained?
Ms Jendoubi:
If an adolescent in a general medical ward in an ordinary hospital developed psychiatric difficulties to the point that it was considered that he or she needed to be detained, exactly the same procedures would be followed as are now for any young person in the Royal Victoria Hospital, Belfast City Hospital, or wherever. A clinician from outside the hospital would need to sign the form for that patient to be detained.
Mr McMinn:
To clarify, patients in a general hospital or in a private-type hospital such as the Ulster Independent Clinic who need to be detained would be detained in a psychiatric hospital, either statutory or private. You cannot be detained in a general hospital; it has to be a psychiatric unit.
Mr McCallister:
The statutory rule proposes no change to the safeguards for detaining and the high mark that you have to reach to detain someone under the regulations.
Ms Jendoubi:
The only thing that the rule will do is that a youngster who is a voluntary patient in the Templepatrick hospital and needs to be detained will not have to be moved to Beechcroft. That person’s treatment can continue in Templepatrick. That is the only difference.
Mr McMinn:
It would not be conducive to patients’ treatment to be switched from one team that is treating them in Templepatrick to another team. Mental health requires continuity of care.
Mr McCallister:
The same would apply if a patient were in an ordinary hospital and had to be detained. If you had to find a young person a bed somewhere and no beds were available in Beechcroft, the trust that that young person was under the care of could buy in the service for Templepatrick or Ballyclare, wherever you want to describe it as.
Mr McMinn:
Templepatrick Road, Ballyclare is the official address.
Ms P Bradley:
It is Ballyclare.
Most of my questions have been answered. It is interesting that you said that, at present, the cost of a patient is about the same as the cost of spot purchasing. Spot purchasing is nothing new. We have been doing it with our elderly care for years, either because we do not have enough statutory homes for elderly care or because a patient has delirium, for example, which takes six months to sort out. A bed, an assessment bed, or whatever, is then spot-purchased. With elderly care, it is often cheaper to do that because it takes the patient out of hospital. It is interesting that the figures do not differ between statutory care and private care. It is still the same amount of money.
I remember that representatives from child and adult mental health services (CAMHS) came and spoke to us when the new home opened. I am very much in favour of spot purchasing. As John said, having to leave Northern Ireland and go across the water puts psychological pressures on families, and it has a detrimental effect on the patient as well. I think that it is a good thing. It is a plus, especially if the figures stack up the same. It would be wonderful if we had that statutory service ourselves, but I am very much in favour of spot purchasing.
Ms Jendoubi:
The implication behind your question is why we did not build Beechcroft bigger? We built Beechcroft at the lowest end of the range of beds that the Bamford review stated the country might need. The Bamford review stated that we might need somewhere between 32 and 64 beds, which was a wide range. We built Beechcroft to hold 33 beds, largely because the Bamford review also stated that it expected to see, in the coming years, community services being improved to the extent that the need for inpatient mental health beds for adolescents would reduce and reduce. Indeed, that is what happening in a large part of Northern Ireland, but there is still a long way to go.
CAMHS is picking up youngsters who otherwise would have been inpatients, so we certainly think that the need for inpatient beds will reduce over the coming years. We think that it is great that there is a facility in Northern Ireland that the trusts can look to rather than having to send youngsters across the water, if that is what most clinically appropriate for those youngsters’ needs. That is much better than the trusts having to fly families over to visit them once a month. It means that, because they are located closer to home, better outcomes can probably be achieved more quickly for the youngsters concerned.
The size of the facility that Priory proposes to builds in Ballyclare is entirely a matter for it. It has clearly done a business case that, as you say, points to its making money from the facility at some point. However, that is entirely a matter for it. On the issue of the extent to which the trusts will use it, the trusts would have to pay the same amount to place somebody in the Ballyclare facility as they would to send somebody across the water. I expect that they will want to exhaust the inpatient beds in the statutory sector before they look to private facilities at all.
The Chairperson:
I have one final question. Will the legislation apply to privately owned facilities for adults?
Ms Jendoubi:
Yes.
The Chairperson:
The legislation will read across?
Ms Jendoubi:
Yes. There just have not been any proposals for privately owned facilities. The legislation will apply to private hospitals.
The Chairperson:
The fact that somebody wants to build such a facility for young people shows that there is a gap in the service being provided here.
I think that it would be useful to park the issue for a week so that we can bring in the Royal College of Psychiatrists. I hear what everybody is saying, and I accept that there are mixed views around the table. I want to bring in the Royal College of Psychiatrists, as well as the Children’s Law Centre, because it is an advocate for young people and has their best interests at heart, to give us a sense of the issue, because I just do not feel that we have enough information. We have had a good presentation and well-answered questions — thank you for that — but I think that it would be useful to have another go at addressing the issue next week to see where we will go with it.
Ms Jendoubi:
Thank you.