Leaving hospital

Page last updated: 12 May 2022

Discharge planning

The MHA Code of Practice is clear that discharge planning should begin as soon as a patient is admitted under the MHA, and all detained patients should have an aftercare plan. In previous reports we have raised our concerns about the quality of aftercare planning.

When people are discharged from hospital, they should have support from a multidisciplinary team that supports both their social needs as well as their clinical needs. In 2019, the Community Mental Health Framework set out proposals to replace the Care Programme Approach (CPA) with a more flexible, responsive and personalised approach. It seems likely that this will be applied to civil (rather than forensic) patients. It recognises the need to adopt clearer multidisciplinary-based approaches and integrating clinical and social care to address people’s holistic needs, rather than the current system of a single care co-ordinator coping with an overwhelming workload.

Although we welcome proposals to develop care co-ordination and planning, they come at a time when we are concerned to see some signs of local authority resources being withdrawn from discharge planning processes. For example, in a review of a ward for older people in October 2020, nearest relatives told us that there had been issues with social workers not being allocated or attending section 117 meetings in order to facilitate safe and appropriate discharge and follow up.

Over the last year the Local Government and Social Care Ombudsman found against a number of clinical commissioning groups for failures under section 117 of the MHA. During this period, we have also investigated and upheld a complaint against a number of agencies relating to a failure to provide statutory aftercare.

A complaint investigation about aftercare provision

We investigated a complaint relating to aftercare provision following an inpatient admission that had included a period detained under section 3 and involved transfer between services.

We upheld many aspects of the complaint. Although aftercare planning should have started from admission, no assessment was carried out despite the patient giving six weeks’ notice of her intention to discharge herself from hospital. A care assessment was finally completed by a duty social worker three months after discharge, following repeated requests from the patient. We found this to be inadequate for reasons that included the following:

this was too late
the assessment did not fully consider underlying entitlement to section 117 aftercare despite recording that she had been detained
there was no record of care needs relating to confirmed diagnoses of autism, OCD, anxiety and trauma
it was wrongly concluded that support needs were met by the patient’s family, although the family was providing support precisely because there were no section 117 aftercare arrangements in place to meet her needs
the assessor did not consider whether existing support should be as part of section 117 aftercare, instead focusing solely on a request for direct payments to fund psychotherapy. As the assessment later concluded, direct payments cannot be used to fund health interventions, but this was not communicated to the complainant in a timely way.

In response to the complaint, the manager of the community mental health and autism team acknowledged the assessment was “limited” but should be viewed as an initial “screening”. As an initial screening, we found that the document failed to meet an acceptable standard for the reasons outlined above. We note this in the context that the complainant justifiably argued that failure to take account of her autism during her hospital admission was a significant contributory factor to her diagnosed conditions on discharge.

The complainant, her current psychiatrist, community psychiatric nurse and social worker told us they contacted had made several attempts to get services to meet their duties to provide aftercare under section 117 of the MHA. Aftercare arrangements were finally in place only after almost three years from leaving hospital.

We recommended that the complainant be reimbursed the money she had spent on providing for her own aftercare while services failed to meet their duties, with compensation for considerable anxiety, distress and loss of opportunity for recovery.

We discuss the working of the CPA and aftercare provision for patients who are remitted back to prison after transfer to hospital under the MHA in the section on the MHA and mentally disordered offenders.

Determining which authority has a duty to provide aftercare

In August 2020, NHS England’s revised guidance, ‘Who Pays? Determining responsibility for NHS payments to providers’, set out the framework to establish which NHS organisation has responsibility for commissioning an individual’s care and which has responsibility for paying for that care. Where the patient usually lives, known as their ‘ordinary place of residence’, will influence this decision.

There can be complicated and long-running disputes over which authorities are responsible for providing aftercare services under MHA section 117 to patients discharged from detention in hospital. This is in part because detention, especially out of area, can complicate the question of ordinary residence, but also because the duties are shared across health services and local authorities. The intense pressures on local authority budgets can mean that accepting liability for a complex aftercare package are likely to increase pressures on already under-funded budget-heads where services have been curtailed to make cost savings. It is not surprising that disputes arise.

Section 117 of the MHA states that where there is a dispute over the location of a person’s ordinary residence, the authorities concerned may ask the Secretary of State make a decision. For example, in 2020, the Secretary of State was asked to determine a case where a patient was detained in Swindon, but had been placed in that local authority as part of an ongoing aftercare package following a previous detention in Worcester. The Secretary of State accepted the argument by Swindon that Worcester should have continued liability, even though this would be contrary to paragraph 19.64 of the Care and Support Act statutory guidance.

In March 2021 the High Court ruled against that decision, upholding the position of the statutory guidance. In response, the Secretary of State has taken the case to the Court of Appeal. The Department for Health and Social Care has stated that decisions around similar cases are paused while the final decision about the correct approach to determining the ordinary residence for people detained under section 117(3) is considered by the Court of Appeal.

We recognise that the government is exploring ways to determine which local area is responsible for the aftercare of a person, particularly in more complicated personal histories that have included placements out of area. But it is important to resolve the ongoing uncertainty quickly and restart dispute resolution, as this could lead to delays in making aftercare arrangements, and could mean that patients are being detained in hospital longer than is clinically necessary, which can be extremely distressing and lead to relapse.

Tackling inequalities

Ward environments

Discharge planning

Determining which authority has a duty to provide aftercare

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