During 2021 to 2022, data shows that more than 50,000 people were detained under the Mental Health Act (NHS Digital). Nine out of ten adults with mental health conditions are supported in primary care (NHS Long Term Plan, p. 68). Some people need more intensive and specialist inpatient care. In 2021 to 2022, more than 97,000 people in England were admitted into NHS-funded mental health, learning disability or autism inpatient care.
While access to inpatient care is important, so is the timely transfer of care back into an outpatient (‘community’) setting, when people’s mental health improves. This is about a careful balance, weighing up the risk of keeping people in inpatient care too long and discharging people too early. The point at which people leave inpatient care can be high risk for a patient’s safety. The transfer to community settings must be managed carefully. It must be ‘purposeful, patient-orientated and recovery-focused’, as detailed in the NHS Long Term Plan (page 71).
The 2016 National Institute for Health and Care Excellence (NICE) guidelines on the ‘transition between inpatient mental health settings and community or care home settings’ are clear about the implications of poor transition. They refer to data from the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH), which shows that recent discharge from hospital continues to be a period of high risk for people dying by suicide. In 2010 to 2020, 14% of all patient deaths by suicide happened within three months of discharge from inpatient care (NCISH Annual Report 2023, page 24). The highest rate of patients dying by suicide in this time was within the first two weeks of leaving hospital.
The right to receive professional and safe standards of care at a time of need is at the heart of the NHS Constitution. And the right to life is protected in UK human rights law. But people deserve far more from our mental health services than being kept alive. They deserve to live well.
People experiencing a mental health crisis often go to emergency departments at hospitals, involving assessment by psychiatric liaison teams followed by admission or discharge back to the community. Data from NHS Digital shows that in 2020 to 2021, there were more than 270,000 attendances at A&E departments in England where a person was recorded as having a primary diagnosis of a psychiatric condition. Although emergency departments are very different environments to inpatient settings, the basic principles of good and safe discharge planning must remain.
When these principles are not supported, it has a human impact and adds pressure to services. When services are overstretched, people may not be able to access the right service for their needs at a particular time. This will have a bearing on what happens when people are discharged from services or when their care is transitioned to a different setting. For example, changes in how police forces will respond to calls related to mental health announced in 2023 under the ‘Right Care, Right Person’ agreement demonstrate the need for clear understanding of each service’s role in responding effectively to a person in crisis.
The cases brought to us show the human cost of mistakes made in discharge planning, both in discharge from inpatient care and following assessment in emergency departments, or when follow-up care falls apart. So that we do not see the same failings in care happening again, when these mistakes happen, the health service must:
- be open and honest in its response
- acknowledge the impact it has had
- commit to learning.