Discussion about admission to hospital under the Mental Health Act in the last year or so has included the observation that too many patients are admitted too late and discharged too soon. This week, the Guardian reported on work they’ve been undertaking using Freedom of Information laws to understand the rates of re-admission to hospital of those who are discharged. It does lend weight to the observation that people are being discharged too early.
3,381 patients were re-admitted to hospital within 30 days of their discharge, and those data came from just 35 of the 54 mental health trusts in England. Extrapolating for all trusts, it suggests approximately 4,927 patients readmitted within a month.
Within the same period of 2022-2023, 1,972 patients were re-admitted within a week of discharge – and this is something regarded as a ‘never’ event in the NHS. Nevertheless, extrapolating again, it suggests 2,794 patients returned within a week. It’s not clear whether this means 2,794 re-admitted within a week and a further 4,927 re-admitted after the first week but by the end of the month OR whether it the first figure is a part of the second. Either way, it’s a lot of people being discharged and then swiftly re-admitted.
EMERGENCY MENTAL HEALTH
I can only imagine the implications of some of this for our emergency and criminal justice services and our Approved Mental Health Professional friends. We can imagine many of these re-admissions occur amidst incidents which require conveyance, polic support of police powers. Some will involve full Mental Health Act assessments coordinated by an AMHP and involving two doctors, who can often be hard to secure for the poor AMHPs involved. I might as well remind you: AMHPs sometimes have to make thirty-five phone calls to secure just one of the two doctors required, given no doctor in this country has a legal obligation to support the AMHP’s need for two doctors to conduct the patient’s assessment. And we’re running low on AMHPs as well, whilst we’re doing this – some areas cannot ensure out of hours provision for AMHPs to consider cases where section 13 MHA imposes a duty on local authorities to ensure they do.
Back in the NHS – I was reminded recently of guidance published in 2019 by the Care Quality Commission on the the operation of section 140 Mental Health Act 1983 – this provision requires Integrated Care Boards in all areas of England (with a similar duty for Local Health Boards in Wales) to ensure certain hospitals to which they have recourse have arrangements in place for urgent admissions to hospitals. The guidance published online, it disappeared within a few hours for reasons that were never fully explained and there was suggestion it would re-appear within a short while after further work. Here we are in 2024 and it still hasn’t been update and re-issued, as far as I can tell. Fortunately, I secured a copy of this guidance.
It doesn’t actually say anything too controversial and I remained stumped as to why it was withdrawn so quickly after publication – it merely sets out the expectations you would naturally expect to see in place if you’ve read the last paragraph about ICB responsibilities to specify hospitals. It talks about specifying them, letting people know, raising awareness and agreeing things across agencies affected by the kinds of incidents that would give rise to people thinking about urgently required admissions – and in all fairness, the disappeared guidance merely reflects further on the requirement in the two Codes of Practice MHA (for England, for Wales) to have joint protocols in place on the operation of s140 MHA.
Form your own view about why it was withdrawn – and do bear in mind if reading it, it is not in operation and has not been re-published.
RE-ADMISSION
So there we go: thousands of people re-admitted within a week and many more thousands re-admitted within a month … all of that in addition to those who are admitted late or not admitted at all —
Of course, there’s little the police, the ambulance service or Emergency Departments can do to directly affect any of this and if early discharge does lead to a problem requiring considering re-admission, AMHPs have little choice but to go through the process again of conducting MHA assessment where called for. All of this made me think of the problem of ‘failure demand’ – a concept involving a failure to do something or to do something right, for a service user. It often involves even more work than doing things correctly, but of course our colleagues in the NHS working inpatient wards are often running at bed capacity, having to identify every day who the “least ill patient” is, in case someone in the community needs admission and they have to decide whether the admission is a more risk critical than an early discharge.
We’ve seen documentaries on the BBC covering this: each ward in a hospital identifying their “least ill” patient and the hospital manager deciding which patient may need to be given early discharge or section 17 leave in the event of a critical admission of someone even more at risk than the person leaving hospital. Only recently, I was asked advice about a situation where the police were guarding someone in an Emergency Department and this was the solution: early discharge for someone not quite ready to go to create a bed space. Sounds awful and unfair, doesn’t it? – but it’s common practice and I’m sure this will be the situation reflected in some of the figures, above.
The trend over recent years has been to continue the seven-decades long process of de-institutionalising mental health care – and this means fewer beds. It also means re-institutionalising people becuase we know there is an established correlation between a reduction in the number of available psychiatric beds for the adult population and the number of people who end up in prison with several years or up to a decade later. And we know late admission and early discharge are linked in His Majesty’s Coroners’ courts to suicide and occasionally, homicide.
It’s just all manner of sensitive and complicated – and it doesn’t look like changing any time soon but the least we can go is get ready for the legal reality that governs all of this, including s140 MHA, joint protocols and professional awareness of the rules and laws which govern them.
Winner of the President’s Medal,
the Royal College of Psychiatrists.
Winner of the Mind Digital Media Award
All opinions expressed are my own – they do not represent the views of any organisation.
(c) Michael Brown, 2024
I try to keep this blog up to date, but inevitably over time, amendments to the law as well as court rulings and other findings from inquests and complaints processes mean it is difficult to ensure all the articles and pages remain current. Please ensure you check all legal issues in particular and take appropriate professional advice where necessary.
Government legislation website – www.legislation.gov.uk
Mental Health Cop 