Are mental health wards discharging patients too quickly?

There continues to be press coverage around delayed discharge from hospital. This coverage tends to focus on speeding up the pace of discharge, but unplanned or early discharge can have a knock-on effect on mental health services, contributing to ‘overwhelmed’ services. Ineffective discharge from mental health settings can lead to higher levels of patient readmission – an article from The Guardian earlier this year revealed that approximately 5,000 patients were readmitted on to mental health wards within a month of discharge. As a practitioner in a frontline mental health service, I see how discharge without support exacerbates pressure on community mental health services and can risk readmission.

Early discharge requires ‘good community support’, but at times that support is not available for people with severe mental illness.

Despite the continued spotlight on improving services, mental health services remain under immense pressure, in both inpatient and community settings. The hospital flow model (the rate of patients being admitted and discharged from hospital) is under increased stress, as the number of patients continue to rise, and bed managers are seen as the ‘gatekeepers’ to access services. Early discharge requires ‘good community support’, but at times that support is not available for people with severe mental illness. While early discharge can be appropriate in some cases, the key to success lies in person-centred discharge planning and an understanding that not ‘one shoe fits all’. 

These challenges show there is a disconnect, as recently discharged patients are at higher risk of suicide in the days and weeks after leaving hospital. Early days post-discharge is when most people are vulnerable, feel alone and require the most support. In acute settings, patients can rely on the therapeutic support of staff, but that level of support is not readily available in the community. Although most people are quite happy at the thought of discharge, they can still feel unprepared and anxious, worried that they may revert to how they were before being admitted.

The underlying issue is that, as well as being unwell, people also feel unheard and dissatisfied with their care pathways. A recent report highlighted several issues, including that people are not involved in care planning, uninformed about discharge plans – sometimes caught unawares, not given adequate community support, and do not have psychosocial factors, such as finances or accommodation, incorporated into their discharge plans. (A survey by Mind in 2017 highlighted the same lapses around discharge planning in mental health settings.) These can leave people feeling alone, with hospital the only place of solace, which is a sad and traumatic state of mind to be in. Regrettably, the patient becomes marginalised, which is not fair or right.

In practice, I have come across individuals who feel unheard and that their complex mental health needs could not be handled in the community but would be better managed on an acute ward.

When people are discharged into the community without support, they feel the system is unempathetic to their struggles. In practice, I have come across individuals who feel unheard and that their complex mental health needs could not be handled in the community but would be better managed on an acute ward. People lack access to good community support and get caught with crisis services trying to support them, which is not sustainable long-term.  

A core part of managing these risks involves early intervention to reduce readmission. I work in Derbyshire, where several mental health services were commissioned to support community patients. These include a crisis house, safe haven and a mental health support line run by P3, a social inclusion charity, in conjunction with wider Derbyshire health partners. P3 offers support and signposting to try to reduce accident and emergency visits where there is an immediate mental health crisis. In addition, Living Well Derbyshire was set up to build the capacity of community mental health provision.

Local services need to consider how to improve joined-up services between the hospital and the community to support better discharge planning, because if these issues remain, people will continue to suffer from preventable readmissions.

As a practitioner, I see people head into the community with high hopes, only to be knocked back down, as there is no service to support them. Despite the support I give, sometimes this is not enough to develop coping skills and people get to a point where readmission is the only feasible option. Coupled with inadequacies in discharge planning, this sets them up to fail before they begin to get better. That people feel safer in hospitals than in their homes is a sad but true reflection of the current situation. In fairness, services have improved over the years, but it is evident that the demand for mental health support exceeds the available resources. Local services need to consider how to improve joined-up services between the hospital and the community to support better discharge planning, because if these issues remain, people will continue to suffer from preventable readmissions.