Although this report focuses on failings in discharge and transitions of care from our casework, it is important that we position this in line with the opportunities that are available to policymakers, practitioners and health leaders to make service improvements. This is so they can act on the learning from these cases and make sure we get transitions of care right the first time for people and their families.
Reform to the Mental Health Act
The main law for providing Mental Health care and securing the rights of people detained under a section in the UK is still the 1983 Mental Health Act. After the Government published its ‘Reforming the Mental Health Act’ white paper in 2021, the draft ‘Mental Health Bill’ was published in June 2022 and detailed government ambitions to bring the law up to date.
In our response to the pre-legislative scrutiny stage of the bill, we supported the proposals to improve the safety and quality of patient care for people detained under the Act and the ambition to increase the power of patients, families and carers. Steps to give more choice and autonomy to people would make treatment more person-centred. We welcomed the proposal for a statutory duty to create a care and treatment plan for every person detained under the Act and that all relevant parties are included in decision-making.
One of the major failings identified in our casework around discharge is the lack of involvement of families and carers around important decisions. Enshrining this in law would go some way to building the foundations for discharge care and planning that puts people, their carers, loved ones and safety at its heart.
We are disappointed by the lack of government progress to bring the desperately needed proposed reforms into law. The long overdue Mental Health Bill is an opportunity to overhaul the way the system works when people are in a mental health crisis and make it fit for the twenty-first century. Mental health campaigners have worked tirelessly for the reform of this law. Their voices must not go unheard, and we will continue to support calls for reform.
Moving from the Care Programme Approach to the Community Mental Health Framework
NHS England’s ‘Community Mental Health Framework for Adults and Older Adults’ explains how health systems should put the NHS Long Term Plan into practice to deliver place-based community mental health care. Published in 2019, it proposed replacing the ‘Care Programme Approach’ (CPA) which had been the guiding principles for delivering care in the community for people diagnosed with a mental health condition. The CPA was brought in during the early 1990s.
The Community Mental Health Framework resulted in 12 early adopter systems getting funding to develop new models of care in line with its principles. It is intended that all health systems will be expected to put in place similar new models by 2024, supported by new investment in relation to the new NHS Long Term Plan.
The principles of the framework are:
- meaningful intervention-based care (rather than generic care coordination)
- a named key worker for all service users supported by a clearer multidisciplinary team
- co-produced, holistic and personalised care and support planning for people living with severe mental health conditions in the community
- better support and involvement of carers
- a more accessible, responsive and flexible system tailored to the health, care and life needs of an individual.
For discharge pathways and support specifically, the framework refers to the ambition of ‘maximising continuity of care’ to make sure there is no care ‘cliff-edge’. It aims to end a system that is centred around ‘referrals, arbitrary thresholds, unsupported transitions and discharge to little or no support’. Instead, it represents a ‘move towards a flexible system that proactively responds to ongoing care needs’.
Rethink Mental Illness reviewed the first year of the Community Mental Health Framework in 2022 and found that ‘systems are at different stages on their journey towards co-production’. Although there was significant evidence of local innovation, challenges could not be ‘fully addressed at a local level’. At this point it was deemed ‘too early to truly evaluate the extent to which its potential is likely to be fully realised’ (‘Getting Started: lessons from the first year of implementing the Community Mental Health Framework’, page 34).
‘Suicide prevention in England’ policy paper
Published in September 2023, the Department of Health and Social Care’s ‘Suicide prevention in England: 5-year cross-sector strategy’ identifies the following priorities for action:
- improve data and evidence around suicide to ensure effective and timely interventions continue to be developed
- tailored support to priority groups including those at higher risk
- address common risk factors at a population level to provide early intervention
- promote online safety and responsible media content to reduce harm and improve support
- provide effective crisis support across sectors
- reduce access to means and methods of suicide
- provide effective bereavement support to those affected by suicide
- make suicide ‘everybody’s business’ to increase collective impact.
In relation to discharge, the paper references a continuing need to make progress on early follow-up on discharge, particularly in the first 72 hours of a person leaving inpatient settings but also through developing ‘effective integrated pathways’.
Guidance developed by safety planning working groups, including around training and quality improvement, will be published by March 2024 with delivery to begin by March 2025.