Being in a mental health crisis is an already distressing experience, yet for hundreds of patients the situation can be exacerbated when they are sent far away from home for treatment due to a lack of beds. Experts call it an "inhumane" practice which was meant to stop in 2021, so why is it still happening?
This article contains mentions of suicide
Simon's mood had been spiralling downwards for weeks. His wife had just given birth to baby Louisa, but rather than feeling joy he was severely depressed.
He couldn't eat or sleep and was convinced his family would be "infinitely better off" without him, he told BBC Access All.
At first, Simon tried to dampen down the thoughts. But they intensified and he reached breaking point. In 2013, Simon, a dad of six, wrote a letter and tried to take his own life.
"I'd said goodbye and was completely at peace with what I was doing," he recounts, nine years on.
He was found shoeless and unconscious and was taken to hospital where the medical team advised he needed inpatient care. Simon agreed.
Then he was told the only bed available was in a private hospital in Harrogate - two hours away.
Simon was given what is known as an inappropriate out of area placement (OAP).
An inappropriate OAP occurs when a seriously ill patient is sent to a different part of the country for treatment because there is high demand and too few beds in their local area.
The Royal College of Psychiatrists (RCPsych) recently called it a "dangerous practice".
It means friends and family can't easily visit and, as well as being in unfamiliar surroundings, patients are also working with unfamiliar teams.
What's more, it should have been "eliminated" 12 months ago.
'I didn't have any shoes'
That commitment was first made in 2016 in the NHS's Five Year Forward View for Mental Health which wanted to achieve "parity of esteem" - putting mental and physical health on an equal footing.
At the time, it stated the practice would be "eliminated entirely by no later than 2020/21".
But, it's now more than a year since that deadline has passed, and research by RCPsych has found that between March 2020 and 2021, nearly 700 people were on an OAP.
It's a "scandal," says Dr Adrian James, President of RCPsych. "It is inhumane and is costing the NHS millions of pounds each year that could be spent helping patients get better.
"I don't think this would happen if you had a heart problem."
According to RCPsych's data, the NHS spent £102m on sourcing OAP beds last year - the equivalent of 900 psychiatric consultants salaries. It's expensive because beds are often in private practices.
But they say the greatest cost is to the patient.
When Simon was admitted, he was able to phone his wife to explain what was happening, but there was time for little else before he was transported to Harrogate.
"Stupid things stick in my memory," he says. "I didn't have any shoes, so I was sent in the ambulance without any."
The fact he was a long way from home became more problematic the longer he was there.
"My wife was reluctant to bring my baby because she was worried my little girl wouldn't recognise me and the effect that would have on my mental health. It definitely set back my recovery."
Ria too has faced this distressing situation. Having been gripped by agoraphobia in 2018 she left home during an August heatwave intending to end her life.
She was quickly picked up by police and sectioned under the Mental Health Act.
"I'd been detained off the streets in the clothes I was wearing," she says. "I ended up in this hospital miles away. No-one could visit me, no-one could bring me clean clothes."
Ria spent nearly four weeks there. "I used to wash my clothes in the shower in the morning and go and stand outside wearing my wet clothes and just dry them in the sun."
There are longer-term impacts too. Being out of area meant Simon's community psychiatric nurse couldn't visit and plan his post-discharge care. Instead, he was required to be well enough to travel by train to meet her.
Marjorie Wallace, CEO of mental health charity Sane, says the government missing its target is "extremely disappointing".
She says: "People have been shunted like parcels to where there's a psychiatric bed. Many times they don't know where they are - they're put in a car and are taken to a hospital somewhere in the countryside so someone is already lonely and disoriented and that experience of being alone is terrifying."
She works with many families. Recently, one 18-year-old man with severe depression and anxiety was sent more than 100 miles away from his family and was accommodated in a Travelodge because there were no beds available in any units.
She says another family, from Cornwall, have clocked up more than 25,000 miles driving across the country to visit their daughter who has been treated in various locations from Somerset to Orpington.
"It's very unfair on families because what they can do? We don't give them a budget to get the transport to visit so they feel helpless and heartbroken."
Marjorie believes the situation has arisen because of the government's "relentless agenda" to close psychiatric units. Since 2000, she says, England has lost half of its beds and now has about 18,000 nationally.
One commonly cited solution to this, beyond commissioning more beds, is improving the quantity of care in the community.
It is something that has been set out in The NHS Long Term Plan. A 10-year plan launched in 2019, which builds upon the 2016 report. It also has a familiar target - to eradicate out of area placements. This time, the timeframe stretches until 2024.
RCPsych says it "welcomed" these ambitions but that it will require "laser focus" to achieve it.
Dr James says investment is needed in "local, properly staffed beds" as well as follow-up care in the community, but adds the workforce crisis also needs to be addressed. Currently, 10% of consultant psychiatrist posts are vacant.
Marjorie is warier of community care becoming the sole solution, saying that it can only work if the service is suitably sufficient and in and outpatient care is joined-up.
She says community mental health teams are often "threadbare" with huge case loads and it needs to become a more robust service to work effectively in this way.
Sane is campaigning for every mental health care trust to have at least five beds available for those in crisis.
"We don't believe it's impossible," she concludes.
But the challenges the NHS now faces have changed since it first made its pledges in 2016 and 2019. Both were made before the Covid-19 pandemic. That alone has increased demand on mental health services with 1.8 million additional referrals expected by 2023.
The cost of living is also set to put further strain on the nation's mental health and NHS budgets.
In a statement, the Department of Health and Social Care said: "Everyone should have access to safe, appropriate mental health care. That's why we are investing an extra £2.3bn per year to transform NHS mental health services by 2024."
Simon, who himself now works for the NHS, spent 14 weeks in hospital. Once he was discharged, he received good, local, support, but he can't understand why the OAP situation hasn't changed.
"We've had so many empty promises that this is going to finish. There needs to be more beds, it can't carry on."
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