The state of health care and adult social care in England 2023/24

The level of demand for adult mental health services continues to grow. Data from the Mental Health Services Data Set (MHSDS) shows there were 600,000 more people in contact with secondary mental health services in June 2024 than there were in June 2019. This reflects a 45% increase in 5 years, which cannot be accounted for by population growth alone.

In June 2024, for every 1,000 people, 34 were in contact with services compared with 24 for every 1,000 people in June 2019.

While the number of people in contact with mental health services is increasing, figures show that there has not been a corresponding rise in the number of interactions people have had with services. This could potentially suggest that not everybody is getting the same level of care.

We can see from data that between June 2022 and June 2024, there was a 21% rise in the number of adults aged 18 to 64 in contact with services, but the number of interactions they had with services only increased by 9%. The picture is worse for children and young people: in the same period, the number of children and young people in contact with mental health services increased by 29%, but the number of interactions they had with mental health services only increased by 11% (figure 7). As well as supporting a growing number of people, mental health services are also receiving an increasing number of referrals from other services.

Figure 7: People in contact with mental health services by age group, April 2022 to June 2024

Source: Mental Health Services Data Set (MHSDS)

Being able to get the right mental health care, as early as possible, can have a significant impact on the trajectory and severity of a person’s illness. However, we are concerned that access to mental health services remains a challenge for many people. As highlighted in this section, research from the Strategy Unit (hosted by ‘NHS Midlands and Lancashire’) shows that people who live in deprived areas, women, and people from ‘other’ ethnic minority groups with mental health needs are more likely to attend urgent and emergency care departments.

Long waits for community mental health care

As reported in last year’s State of Care, we continue to be concerned that a high demand for community mental health services – without the capacity to meet it – is affecting people’s ability to get the help they need, when they need it. Our regulatory activity has found evidence of people having long waits from referral to receiving treatment in the community.

Access to care was one of the key concerns we raised in our special review of Nottinghamshire Healthcare NHS Foundation Trust (NHFT). In this review, we found that high demand and lengthy waiting lists meant that people were not able to get the care they needed when they needed it. Many people told us they were unhappy with access to community mental health and crisis services at NHFT, with many reporting that they felt frustrated by “immense” or “extraordinary” waiting times:

I have now been on it [waiting list] over 1 year, and was told when I first asked for help, that it would be 3 to 4 months. I was totally forgotten after my initial assessment, which was traumatic… I have had to chase numerous times to get feedback, updates etc, I have gone backwards on the waiting list.

Our findings from Nottingham are not unique. Our analysis of free text responses to the 2023 NHS Community mental health survey found that people reported having to wait several months, and in some cases several years, between referral, assessment, and treatment.

While a few people described seeking alternative private health care, this was not an option for many people. This can lead to inequity between those who can afford private care and so avoid the waits, and those who cannot.

Results from the survey show that children and young people had a worse experience than adults, and faced long waiting times at all stages of care. This included waits for initial assessments, diagnoses, medicines, and therapies. Of the respondents who had used children and young people’s mental health services, 61% (327 out of 534) said they waited too long for their first appointment for treatment.

Waiting times for children and young people are variable. This is supported by findings from the March 2024 Children’s Commissioner’s report on children’s mental health services. This reported that in 2022/23, the average (median) waiting time of the 305,000 children and young people entering treatment (receiving their second contact from children and young people’s mental health services) was 35 days or 108 days (mean). The median wait varied widely between integrated care board (ICB) area from 5 days to 79 days. This disparity suggests that services are operating in a complex and demanding environment, and are continually having to prioritise.

For the 270,300 children and young people recorded as still waiting at the end of the year for their second contact, they waited on average 142 days (median) or 359 days (mean).

Some young people who responded to the NHS Community mental health survey also described being denied support on multiple occasions before being accepted by mental health services:

I was turned away the first time because I wasn't bad enough! Which is ridiculous because I had expressed suicidal thoughts.

We are also concerned that because support from children and young people’s mental health services typically ends at 18 years old, there is an increased risk that older teenagers (people aged 16 to 18) may fall through the gaps. For example, one person described how, “[I was] told that I was nearly 18 so no point in starting treatment.”

The consequence of not getting support is highlighted by findings from the research we commissioned from the Strategy Unit into mental health attendances in urgent and emergency care settings. This found that people aged 18 to 21 consistently have the highest rates of presentation for mental health issues at both emergency departments and urgent care centres. In addition, they found that children and young people aged 0 to 17 were the only age group to have an increase in attendance rates at type 1 urgent and emergency services (A&Es) since 2019/20.

These findings show that not getting the right help at the right time can lead to symptoms getting worse and people ending up in crisis and/or inappropriate environments, such as urgent and emergency care. We heard that deterioration in people’s conditions can be compounded by poor communication from providers while waiting. One respondent to the NHS Community mental health survey described how, “…not knowing feeds my anxiety and depression. Instead of helping they are making it worse.”

Figures from NHS England’s Mental Health Services Data Set (MHSDS) show that the number of adults with a serious mental illness who accessed community mental health services increased from nearly 560,000 to just over 600,0000 between June 2023 and June 2024 (an 8.9% increase).

People’s need for mental health services varies depending on where they live. Data from MHSDS shows that people with a serious mental illness who live in deprived areas are more likely to be in contact with services (figure 8).

Figure 8: Adults per 100,000 population with serious mental illness who received 2 or more care contacts by deprivation decile, 2022/23

Source: NHS Digital, Mental Health Bulletin

In June 2024 very urgent referrals to crisis teams for adults were 45% higher than in June 2023 (figure 9). These figures support the findings from our special review of Nottinghamshire Healthcare NHS Foundation Trust, where we identified high levels of need for the trust’s crisis service. This was potentially being exacerbated by the waiting times for people who need longer-term support from the community teams.

Figure 9: New very urgent crisis team referrals for people aged 18 and over

Source: Mental Health Services Data Set (MHSDS)

Best practice guidelines from the Royal College of Psychiatrists state that crisis teams should see very urgent referrals within 4 hours, and urgent referrals within 24 hours. In June 2024, only 20% of adults with a very urgent referral were seen face-to-face within the 4-hour standard.

When people reach crisis point but can’t get help from specialist crisis services, they may need urgent care in hospital. The research by the Strategy Unit shows that across England in 2023/24, people with a primary diagnosis of a mental health condition made 200,000 attendances to emergency departments and 20,000 attendances to urgent care (type 3) units.

This research also showed that some people are more likely to need help from urgent and emergency services than others. People who live in deprived areas, children and young people, people from ‘other’ ethnic minority groups, including Chinese and Arab people, and women all present at urgent and emergency care departments at higher-than-average rates. In particular, it highlighted that urgent and emergency care attendance rates are over 3 times higher for people who live in the most deprived areas than for people from the least deprived areas. While the majority of these patients are known to specialist mental health providers, a substantial minority (20% attending type 1 emergency (A&E) departments) are not.

As we highlighted in our 2020 report Assessment of mental health services in acute trusts, emergency departments are often not suitable environments for people experiencing a mental health crisis. While they may be able to provide a safe physical environment, they are not therapeutic for people with mental health needs and can make people’s mental and physical health worse.

Despite this, the Strategy Unit research shows that in 2023/24, people presenting with mental health issues waited longer in the emergency department for assessment, treatment and discharge. The average emergency department ‘pathway’ was almost an hour longer for mental health patients.

People are still facing long waits in an emergency department while they wait for a mental health bed to become available. This issue was raised by people in their comments through Give feedback on care:

My daughter was admitted to [the ward] around 9pm, having waited 5 days in A&E for a place.

I joined the 10 to 15 psychiatric patients waiting in A&E for psychiatric beds. I was informed that there were 60 patients on the bed list and no beds available.

Marlon’s story highlights the importance and positive impact of getting access to the right care, in a timely way.

Lack of inpatient beds

High levels of bed occupancy in mental health hospitals are a known indicator of pressure in other parts of the system. Over the last 13 years, mental health bed occupancy has increased from around 86.6% to 90.4%.

Lack of inpatient beds, combined with a lack of capacity across the system, including community care, can lead to people being sent to a hospital miles away from home. We know that these out-of-area placements can be hugely detrimental to people’s recovery. Not only can it leave people feeling isolated because friends and family are often not able to visit, but it can also increase the risk of closed cultures developing in services. In addition, as reported in our 2022/23 Mental Health Act annual report, it can increase challenges around communication with community mental health teams and securing appropriate community support back in the person’s local area.

Despite the previous government’s commitment in 2021 to ending out-of-area placements, more than 1,500 people were in an inappropriate out-of-area placement at the end of June 2024. This, together with the high occupancy rates, suggests there isn’t enough capacity in inpatient settings to meet the needs of patients being referred from the community.

Lack of capacity in the system has also led to people under the age of 16 being placed in inappropriate settings (wards designated for the treatment of adults). Figures from MHSDS show the number of adult bed days within a reporting period that are used by children, but they do not show the number of children. For example, 10 bed days could mean that 1 child may have been on an adult ward for 10 days in a month, or 10 children may have been on an adult ward for 1 day each. In 2022/23, across England children and young people spent on average 313 bed days a month on adult wards, reflecting the high need for specialist mental health beds for children and young people under 18 years.

Guidance from NHS England is clear that people should be discharged to a less restrictive setting as soon as the purpose of their admission is met and they no longer require care and treatment that can only be provided in hospital.

The NHS Long Term Plan set out the ambition that people should have inpatient stays of no longer than 32 days. However, figures show that for adults discharged in June 2024, nearly 2,500 had stays of 60 days, down from a recent high of over 3,200 in March 2024. Nearly 1,400 had stays of over 90 days also down from nearly 1,900 in March 2024. Longer stays may be due to people being more ill on admission, which may take longer to treat, as well as other factors such as being placed out of area, or other issues such as housing.

Issues with staff shortages may also have an impact on the length of inpatient stays. Our 2022/23 Mental Health Act annual report shows the findings from our monitoring activity. We’ve seen how staff shortages have affected patients’ access to therapeutic activities, stopped them from taking planned leave, or even prevented them from accessing fresh air – all of which are vital in creating therapeutic environments and supporting people’s recovery.

Data from NHS England shows that people aged 18 to 64 from the most deprived areas of England are far more likely to have longer stays in hospital. It shows that for every 100,000 people from the most deprived areas:

• 65 people have stays longer than 60 days compared with 14 people from the least deprived areas
• 37 people stay longer than 90 days compared with 7 people from the least deprived areas.

There are also stark differences for some people from ethnic minority backgrounds, especially for people in Black ethnic groups. The data shows that in 2022/23, for every 100,000 of the population:

• 100 Black people stayed in hospital for longer than 60 days, compared with 25 white people (the group with the lowest number of people)
• 55 Black people stayed in hospital for longer than 90 days, compared with 15 white people (the group with the lowest number of people).

Quality of mental health care

Generally, when people can get access to mental health services, they are often satisfied with their treatment, and grateful to staff.

However, people are still struggling to get person-centred care at a time that works for them.

The impact of staffing on the quality of care

The mental health workforce grew by nearly 40,000 full time equivalent (FTE) members of staff (35%) between March 2019 and March 2024. While this is a positive improvement, we remain concerned about the impact of difficulties in recruiting staff to specific, skilled roles.

Problems with staffing and skill mix was a key concern identified through our special review of services at Nottinghamshire Healthcare NHS Foundation Trust (NHFT). Evidence from our regulatory activity shows that services across the country are currently facing many of the same challenges in recruiting staff including nurses, psychologists, occupational therapists and consultant psychiatrists – all of which are affecting the capacity to deliver services.

During our review of NHFT, people using services told us they felt there were not enough staff across many locations. We found several vacancies for psychologists across all teams, and not all teams had access to the same number of practitioners. In addition, issues around caseloads and the make-up and size of the teams meant that people were facing lengthy waits to receive care and treatment.

Availability of appointments

We have also heard how staffing numbers and staff turnover is affecting the availability and regularity of appointments. Respondents to the NHS Community mental health survey reported difficulties in making regular appointments, as well as problems with not receiving treatment for a long enough period to meet their needs. People described the impact this had on them:

Since February I've been left with no therapy, messed around and have declined ever since. I was promised I'd have therapy back in a short amount of time after [my therapist] left, and it's currently been 8 months and no sign of help.

I have had so many experiences of being promised support and not getting it – and then being essentially told off for being upset – that I have no faith in the mental health service. There is no trust, and I find interaction with the team triggers anxiety and distress to the point that I avoid interaction. There is no continuity of care and I’ve rarely seen the same clinician twice.

This was a particular concern for young people, with only 39% (468 out of 1,211 respondents) saying they were given enough time to discuss their needs and treatment, compared with a national average of 50%.

Issues around access and availability of appointments have had negative effects on people. We heard from people who suffered negative impacts such as worsening their condition and negatively affecting personal relationships. We also heard instances of people gaining weight or self-medicating to cope.

Feeling that there is no support could also risk people withdrawing from the mental health system altogether. As highlighted in our Special review of mental health services at Nottinghamshire Healthcare NHS Foundation Trust: Part 2, disengagement with services is common for people with mental health problems. Through our special review, we found that the people who had disengaged from mental health services had experienced large gaps in support from community mental health teams, with gaps between visits ranging from several weeks to over 2 months in one case.

Children and young people are more at risk of disengaging from services. Data from MHSDS shows in 2023/24, over a million children and young people each year did not attend their care contact, with half missed with no advance warning. Reasons for this could include their needs not being met or a deterioration in their mental health condition. Not attending appointments increases risks to children and young people and could lead to worse outcomes for them.

Nevertheless, at the same time, some young people who responded to the NHS Community mental health survey have described positive experiences around availability of appointments. These included examples of staff being flexible with appointments and arranging home visits – in one case by arranging home visits to accommodate the individual needs and disabilities for one person.

The type of appointment offered can also have an impact on care. Respondents to the NHS Community mental health survey described problems such as being given phone-based appointments when they struggle to communicate by phone. For example, through our online Give feedback on care service, autistic people described being offered telephone or online consultations, which they found challenging:

I am struggling with phone appointments as I struggle to have these very personal conversations over the phone and I am not able to open up fully.

Many young people said they would prefer to have more face-to-face appointments, rather than the telephone or video calls that were offered. For example, one young person said that a face-to-face appointment, “gives patients a physical connection and builds trust with their therapist. Online just feels insensitive in serious cases.”

Are people being kept safe?

Staffing levels

As we reported in last year’s Mental Health Act Annual report, not having the right levels of suitably qualified staff can have a huge impact on the safety of people who use services and the quality of care they receive. Through our monitoring activity, we saw examples of staffing shortages preventing people from accessing therapeutic activities, stopping them from taking planned leave, or even preventing them from accessing fresh air.

We have similar concerns for people who need community mental health care. As highlighted in the section on quality, problems with recruitment have led to issues with capacity in some services. Long waits and not being able to access care when people need it increases risks. For example, during our special review of services at Nottinghamshire Healthcare NHS Foundation Trust we found that too many patients did not have a care co-ordinator. Without this oversight, staff and services cannot monitor any deterioration of people’s condition, putting them at risk of harm.

Although vacancy rates have been decreasing across the NHS, they are still persistently higher in mental health services compared with NHS hospital and community health staff as a whole. Concerns about vacancies within multidisciplinary teams has been a theme in some of our inspection reports. In particular, in line with our findings from the special review of Nottinghamshire Healthcare NHS Foundation Trust, we have found that many services have experienced difficulties in filling posts for psychologists and occupational therapists.

Not having enough staff puts additional pressure on the existing workforce. Results from the 2023 NHS staff survey showed that 58% of the mental health workforce reported working unpaid hours on a weekly basis – higher than the national average of 53%. These figures were even higher for roles including occupational therapists, nurses, clinical psychologists, consultants and psychotherapists, with clinical psychologists and consultants having the highest proportion of respondents who reported working unpaid hours (70% and 79% respectively).

Working under sustained pressure poses a challenge to the safe, effective care of people using mental health services. Results of the NHS staff survey continue to show poorer results from mental health workers when asked if they would want their friends and relatives to be treated in their organisation (64% in 2023, compared with a high of 70% in 2020), showing that they feel the standard of care is not high enough.

Ward environments

The safety of mental health wards continues to cause concern. Lack of resources, ageing estates and poorly designed facilities can lead to issues around privacy and dignity for patients, as well as compromise the safety of both patients and staff.

Under the Standards of the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment, patients have a right to a suitable standard of environment. However, during inspections, we have found wards that were not clean, with food on floors, ripped furniture and a failure to ensure appropriate hygiene in food preparation areas. In some cases, wards have closed due to the environments being unsafe.

The environment of inpatient wards was a particular concern that autistic people raised with us through Give feedback on care. Many people (including autistic people and their loved ones) told us about poor ward conditions, including environments that had a negative effect on their sensory perceptions, such as lights, noise and temperature:

She is in a big room with lots of lights, it's too hot, there's lots of noise and strange people are sitting at the bottom of the bed staring at her all the time.

I can’t sleep because of the noise here, I have very sensitive hearing and hypervigilance; the office door slamming shut constantly is stopping me falling asleep, I wear ear plugs for bed, I’ve even [taken] some meds for sleep and I still can’t sleep; I don’t think the lack of sleep is helping at all.

Not only does this indicate that reasonable adjustments for autistic people are not always considered on inpatient wards, but it may breach service provision requirements under the Equality Act 2010.

The poor quality of seclusion rooms within forensic services has been highlighted in a number of our inspection reports. On one inspection, we found a seclusion room with no natural light and intercom facilities that did not work, which made it difficult for patients to communicate with staff.

We are also concerned about the rise in the number of mixed sex accommodation breaches, which have safety implications for patients. People affected by mental ill health can at times act in disinhibited ways or may lack the mental capacity to make sound decisions about relationships. They may also have experienced abuse in the past, which might have contributed to their mental ill health, and which might leave them at risk of being exploited by others.

The Mental Health Act Code of Practice highlights that women-only environments are important because of this increased risk of sexual and physical abuse, and previous trauma. It also states that consideration should be given to the needs of transgender patients.

The NHS Constitution is clear that people admitted to hospital will not have to share sleeping accommodation with patients of the opposite sex. It has been mandatory for providers to report all mixed sex accommodation breaches since 2011. In the last 5 years, we have seen a gradual increase in the number of mixed sex accommodation breaches reported in mental health services, with 47,489 breaches between July 2023 and June 2024, compared with 42,200 breaches between July 2022 and June 2023.

The increase is also reflected in the rate of breaches for every 1,000 finished consultant episodes, which has increased every year from 1.3 in June 2022, to 2.1 in June 2023 to 2.2 in June 2024 (figure 10). Alongside this increase, research shows a rise in the number of sexual safety incidents, including sexual assaults, in mental health wards.

Figure 10: Mixed-sex accommodation breaches per 1,000 finished consultant episodes

Source: NHS England Mixed-Sex Accommodation Data. February 2020 data excluded from the chart because data for this month was unusually high having included additional breaches which had been under reported in previous months