Introduction
“I once heard a description of a patient journey as being like moving between islands – you were fine if you were on an island (i.e. in a service) but, if you had to move to another island (transition, discharge or referral on) it was like sailing and trying to find a port to have your entry visa checked and get through customs. If it wasn’t up to scratch, they wouldn’t let you off the boat and you would have to sail back or find another island, or you could get stuck in customs while they checked you in.”
Geoff Brennan, Safewards initiative Clinical Supervisor, Kings College London
“The discharge process should be about enabling people to lead their best lives.”
Sarah Rae, MINDS NIHR Study Joint Lead Applicant and Mental Health Expert by Experience
The public understanding of the ‘bed backlog’ is well established around NHS acute hospital and emergency settings. Ambulance queues outside A&E departments give a picture of a disjointed health and social care system, leaving people ‘stranded’ while waiting for follow-up care and affecting patients elsewhere.
The Care Quality Commission’s (CQC) most recent ‘State of Care’ report points to a similar backlog in mental health services, where gaps in community care provision are putting ‘pressure on mental health inpatient services … leading to people being cared for in inappropriate environments – often in emergency departments’ (page 6). This is combined with ‘an increasing pressure to discharge people from hospital’ (page 37).
Headlines typically focus on the crisis in accessing mental health services, long waiting lists and the patchwork of availability of care across the country, all made worse by the COVID-19 pandemic. Public inquiries have looked for answers and radical change in response to the tragic deaths of patients in inpatient mental health settings, which are the very places that should offer safety for those in need.
The Department of Health and Social Care has commissioned a series of national investigations into inpatient care led by the Health Services Safety Investigations Body (HSSIB). Launched in autumn 2023, these investigations are looking at how providers of inpatient mental health services learn:
- from deaths in their care
- how young people are cared for
- how ‘out-of-area’ placements are handled
- how to develop a safe, therapeutic staffing model.
It is crucial to acknowledge the immense efforts of the vast majority of the mental health workforce to deliver the very best care possible with patients’ needs at its core. To make sure mental health services can properly respond to a surge in demand where one of the biggest challenges is staff recruitment and retention (CQC, page 50), we cannot just look at the front door to services in community and crisis care. We need to give equal attention to how people move on from inpatient and emergency settings back to their homes.
We must not overlook patient safety in the transition from inpatient to community care and beyond. The temptation is to concentrate on speed, with data focused on the number of days from admission to discharge. While shorter stays should be the ambition for patients who are well enough to leave hospital, this cannot come at the cost of patient safety, supported recovery and what is right for the individual, their carers and loved ones.
When we talk about discharge planning and transitions of care, we are talking about how the experience of people leaving hospital, either to their home or to a different community-based service, is managed. Unsafe discharge potentially leads to poorer outcomes for patients and the risk of repeated cycles of readmission: a revolving door in and out of services.
Developing our report
We analysed more than 100 complaints that we investigated between April 2020 to September 2023 where we had found failings in care that involved mental health care. Complaints related to discharge and transitions in care emerged as common themes across these cases. The six cases in this report show where we have found failings specifically around discharge from inpatient mental health services or emergency departments caring for someone with a mental health condition.
The cases represent a broader trend of issues in planning, communication and care, both during and after discharge. These transfers of care offer an insight into people’s journey through a fragmented system and are not necessarily unique to mental health. Problems that happen around the point of discharge from inpatient care often reflect wider issues in that system, just as improvements in the working culture and processes around discharge can help improve care across the wider pathway.
As well as analysing the evidence from complaints, we spoke to people with personal experience of discharge from inpatient mental health settings, people working in mental health services, policymakers and representatives from the voluntary sector.
We use this evidence to make recommendations about how good discharge should be carried out and the wider values that guide discharge care. We recognise the immense pressure on the NHS and wider services. We present recommendations that will help avoid the problem of poorly planned discharge which has a negative effect on people, families and resource in the health system.
Download a PDF of the report [PDF 730KB]
Content warning
This report includes references to suicide. It discusses cases where people have taken their own lives.
If any of the issues in this report have affected you, the Samaritans can help. You can call them for free on 116 123, email them at jo@samaritans.org or visit www.samaritans.org to find your nearest branch.