Mental health services have always been the poor relation to physical health services in the NHS and they have been chronically underfunded and understaffed. Recent commitments to improving mental health services, including providing more funding, have had little impact on front-line care and the system remains in crisis.
The involvement of private companies is longstanding, both in the provision of in-patient care and in the area of counselling and the treatment of addiction. Recent issues have focused on the poor quality of in-patient care provided by private companies, including The Huntercombe Group and Cygnet Healthcare.
The scope of mental health services is broad and they are provided by NHS England, CCGs and local councils.
There are two aspects to the privatisation of mental health services:
- Contracts with non-NHS organisations, including private companies, community interest companies and charities, and
- Difficulties accessing NHS care pushing people to go private - rationing.
Over the past three years the NHS Support Federation has monitored contract activity in mental health via the publication of contract awards on two databases. However, contract awards are often not published, so any figures for the value of awards is an under-estimate.
According to this data, in the most recent year 2017/18, contract awards to provide mental health services were valued at £947 million, and non-NHS organisations were awarded 65% of these valued at £611 million.
The size and type of contract used for mental health services varies across areas. In some areas, framework contracts are in place, these list a number of providers which can be contacted by the CCGs in the area seeking providers of mental health services, such as inpatient beds. Many local councils also have framework agreements for the provision of substance misuse services, one of the main areas covered by the council's responsibilities for public health.
For example in 2016, CCGs in Sussex awarded a framework contract entitled - Specialist Inpatient Adult Mental Health Services and Specialist Inpatient and Treatment for Adults with a Learning Disability - to a number of organisations, including Cygnet Healthcare, Partnerships in Care, The Priory Group, St Andrews Healthcare, the Huntercombe Group, plus a number of NHS trusts. This framework agreement was worth £27 million over three years.
In other areas, individual CCGs and councils have contracts with a number of organisations. In 2018 for example, Greater Huddersfield CCGs reports several mental health-related contracts, including ones with The Priory Group, Thomas Owen Care Ltd, Cygnet Healthcare Ltd and WomenCentre. The local council Kirklees Council reports that it has contracts with six organisations (all charity or not-for-profit) for mental health services.
Historically, mental health services have been underfunded and not given the same priority as physical health services. In recent years there have been a number of commitments to changing the status of mental health services, including providing more funding. However, it is clear that much of the promised extra money has not made its way to the front line, nor has the funding matched the increase in demand. Mental health services are experiencing a shortage of specialist nurses and psychiatrists and a shortage of suitable buildings.
A recent July 2018 report by the Association of Child Psychotherapists, noted that there is a “serious and worsening crisis” in the service. This report is just the latest in a long line of reports highlighting the crisis in the services.
One major result of years and years of underfunding and increasing demand is that accessing mental health services is becoming harder and harder. The services are associated with long waiting times for appointments, particularly in the area of children and adolescent services. Waits of as long as 18 months have been reported. It has also been reported that the threshold for receiving treatment has increased, with people having to be suicidal before they are referred for treatment.
It is no wonder then that more and more people are turning to the private sector for the treatment of mental health conditions. A report in October 2017 found that one in five children referred for treatment in England cannot be seen by overstretched child and adolescent mental health services, and some families end up seeking private care.
Another study found that since 2016, the number of people booking private counselling sessions has increased by 65%, and over three-quarters of patients revealed that they went private because NHS waiting lists are too long.
In August 2018, the charity Wellspring based in the SouthWest which provides very low cost counselling services, reported a massive increase in people contacting the service. They put this down to NHS waiting lists and an increase in publicity surrounding mental health conditions.
For years, private companies have made a profit from treating people with addictions, but cuts to NHS services mean that this area is seeing major growth. In August 2018, the US-based multinational corporation Eli Global invested in UK Addiction Treatment Centres (Ukat), which runs seven treatment facilities in England and is the largest private addiction treatment firm in the UK by patient volume. Ukat has reported unprecedented demand for treatment.
The growth in private companies can be put down to cuts to local authorities’ public health grant funding; spending on drug and alcohol services has been cut by 25% since 2013, according to Paul Hayes, the chief executive of Collective Voice, an umbrella group of UK addiction charities. In 2013 was when the National Treatment Agency for Substance Misuse was abolished and responsibility for these services was placed in the hands of local councils.
The growth of people being forced to self-refer to the private sector for costly treatment is set to escalate as funding for NHS services is being reduced still further - by £531m between 2015 and 2020 - and local authorities can no longer fund drug and alcohol addiction units.
Another issue that pushes people to the private sector is the short duration of treatment available on the NHS. Patients then feel that they need to go private to complete any therapy.
Quality of Care
Recent years have seen several incidents of appalling lack of care of in-patients in private hospitals, in particular in the area of drug and alcohol addiction and in the treatment of children and young adults.
In November 2017, the CQC published a report on independent residential rehabilitation units treating drug and alcohol addiction. The report concluded that people are being put at risk of harm by many of these services.
The CQC's investigation found that nearly three-quarters of private clinics were failing to hit regulatory standards of care. The CQC inspected 68 independent services providing residential detoxification services over the last two years.
Over the last two years, the CQC has required 49 providers to make improvements because they had breached regulations of the Health and Social Care Act 2012 and failed to meet fundamental standards of care.
In addition, the CQC took enforcement action against eight providers and 41 providers breached two or more regulations and 25 breached three or more.
In November 2018, The Times published a damning article exposing the companies and charities that make millions by providing substandard care to NHS patients. The article included one case where the directors of a psychiatric hospital that was found to provide substandard care to NHS patients by the CQC, had paid almost £25 million into a secretive trust in Belize. The article noted that the company had received £26.3 million for services over 18 months in 2016-17 from NHS contracts.
Another case highlighted by The Times investigation was the charity St Andrews Healthcare which paid its chief executive, Gil Baldwin, £496,000 before he left last year, and 76 employees salaries of more than £100,000. The charity's facilities included a private hospital where a 17-year-old girl was locked in a cell-like room with only a mattress and chair and passed meals through a hatch in the door. Three psychiatric services run by the charity, and its overall services, had been judged in need of improvement by the CQC.
The Priory Group
One of the largest private providers of mental health services to the NHS, The Priory Group, consisting of The Priory and Partnerships in Care, has hit the headlines several times for its involvement in patient deaths. These include in 2012 14 year old Amy El-Keria, who died at Ticehurst House in East Sussex, in 2014 17-year-old Sara Green, who died in the Priory Royal in Cheadle, and in March 2016, the Priory and Solent NHS Trust admitted liability for the death of 15-year-old George Werb, who had been a patient at the Priory Hospital Southampton.
More recently in February 2019, the Priory's hospital for children with learning disabilities in High Wycombe was closed, following a CQC report that gave the unit an overall rating of 'inadequate'. The CQC found the hospital “not adequately equipped to care for young people with complex needs”. The hospital had only opened in April 2018 and catered for children aged 13 to 17 with learning disabilities and/or autism. In 2018, two of the company's hospitals, its Roehampton hospital in Wandsworth and its hospital in Southgate, North London, received very critical CQC reports. Both were rated “requires improvement” overall by the CQC, following unannounced inspections. The CQC rated the Southgate hospital as “inadequate” for safety and noted several concerns across its child and adolescent mental health services, acute adult wards and substance misuse services.
The Huntercombe Group
Hospitals run by the Huntercombe Group have received particularly critical reports after inspections by the CQC. In 2016, its hospital in Stafford was placed in special measures and told to urgently improve in 24 areas.
In September 2017, Watcombe Hall, was closed indefinitely after the local NHS hospital raised concerns about the number of young patients being admitted from the unit suffering from malnutrition and dehydration. In July 2018, a third unit run by Huntercombe, the Roehampton hospital in Wandsworth, was put in special measures by the CQC following a rating of 'inadequate'. The 'inadequate' rating was given in the categories safety and well-led.
In December 2018, an inspection by the CQC of the company's hospital in Norwich found serious concerns. The CQC took immediate action to protect those using the service, including enforcement action to remove the registration for the hospital. The Huntercombe Group then closed the service and the children and adolescents had to be found places elsewhere.
Hospitals run by Cygnet Healthcare have also been criticised.
The company's Sheffield hospital was rated 'inadequate' by the CQC in July 2017 and its hospital in Woking received a damning CQC report in October 2017 and was also rated 'inadequate'. After an inspection in February 2018, the CQC rated Wyke Hospital, near Huddersfield as 'requires improvement' and noted a number of concerns.
The CQC inspected the Knole Ward at the Cygnet Hospital at Godden Green, in Kent, in July and August 2017 after it was informed of concerns about the safe care and treatment of young people.
As a result of the visits restrictions on the provider’s registration were imposed by the CQC, saying it could not admit any young person to the ward without prior agreement with the CQC. This remained in place for a month.
A two-tier system
The chronic underfunding of mental health services has led to long waiting times and a reduction in treatment times. This has pushed people into the private sector, effectively creating a two-tier system; timely and appropriate care for mental health conditions being only available for those who can pay, and for those who can't pay there is the likelihood of long waits and/or insufficient treatment.
Leading companies in the mental health sector include:
The Priory Group
One of the largest private providers of mental health services to the NHS, The Priory Group, consists of The Priory and Partnerships in Care. The company is owned by Acadia Healthcare, a US company specialising in behavioural care. See our company overview here.
The Huntercombe Group
Huntercombe has 22 hospitals and centres in England and Scotland. The company specialises in looking after people who have mental health problems or who have learning difficulties or brain injuries. Huntercombe Group is part of the Four Seasons Health Care Group, the UK’s largest independent elderly and specialist care provider. The Group is run as three separate businesses: Four Seasons Health Care (FSHC), which provides care services to the elderly; brighterkind, which focuses on private residential and nursing care; and The Huntercombe Group (THG), which provides specialised services in mental health, brain injury and neurodisability. The Four Seasons Group is ultimately owned by Terra Firma, a private equity company.
Cygnet Healthcare was established in 1988 and specialises in providing services to those with mental health problems people with learning difficulties. The company offers 11 services, including secure accommodation, personality disorder, CAMHS, eating disorders, autistic spectrum disorder and neuropsychiatric. In mid-2018, Cygnet acquired Danshell Healthcare, which has 25 homes specialising in the care of people with learning disabilities and autism. The company is ultimately owned by Universal Health Services Inc, a US company.