Reflections on Improving Inpatient Mental Health Flow and Outcomes

On Monday, we were excited to be part of the Better Care Fund’s Learning Lunch on Improving Inpatient Mental Health Flow and Outcomes in Sussex ICS. This webinar sought to shine a spotlight on work done in partnership with the Sussex system (Sussex Partnership NHS Foundation Trust, Brighton & Hove City Council, East Sussex County Council, West Sussex County Council and Sussex ICB), the Local Government Association’s Better Care Fund team and IMPOWER Consulting to undertake a gap analysis against DHSC’s ‘Discharge from mental health inpatient settings’ guidance. The aims of this work were to develop an action plan to improve outcomes for people, reduce bed days for people who are clinically ready for discharge (CRFD) and improve system flow.

As pressure continuously builds on mental health systems, and as local areas grapple with ever-increasing complexity, more potential solutions to help improve flow are being touted at national levels. For instance, this week, we read with interest Annabelle Collins’ article in the HSJ about the potential opportunities – and challenges – presented by implementing mental health A&E programmes as part of the NHS’s 10-Year Health Plan.

Solutions like this might be one part of the puzzle. However, it will also be critical to directly tackle the underlying causes of poor mental health flow. With ever pressurised budgets, how will gaps in commissioning both preventative and acute provision be tackled? How will national clinical skills shortages in inpatient and community mental health care be addressed? How will frontline staff – in inpatient wards, psychiatric liaisons, social care and so many others – be supported and empowered to deliver meaningful change that directly improves outcomes and performance? And, crucially, how will the conditions be created for strong collaboration for local mental health systems to deliver all of this at the scale and pace required?

Pressure on Urgent and Emergency Care

The pressure on acute care caused by poor mental health flow was one of the topics discussed by attendees to Monday’s Learning Lunch. As Collins rightly points out in the HSJ, despite acutes’ best efforts, stretched staff and facilities often mean very long waiting times for assessments for people in mental health crises, let alone in putting the support they need in place. In addition to resulting in poorer outcomes for people, this pressure can also put huge strain on already scare resources – all in terms of staff time, finances and operations.

It is critical to widen the lens to properly understand and address these challenges. For instance, finding the right housing for people exiting mental health inpatient care – another hot topic in Monday’s session – can cause significant bed days lost for people who are clinically ready for discharge (CRFD), and directly contribute to long waiting lists for mental health beds. This can especially be the case in complex housing landscapes, e.g. in two-tiered systems, or in systems where Trusts routinely work with multiple housing authorities.

Attendees also discussed how to best make the case for investment into mental health flow, in a context of what can feel like ever-diminishing resources. This can be especially tricky with mental health, where statutory duties are often dispersed across a wide range of partner organisations. However, as Sussex colleagues pointed out, this is possible with a clear and compelling rationale, and a solid understanding of benefits that can be achieved for all system partners.

The uniqueness of mental health

Another source of discussion was recognition of the uniqueness of delivering change in mental health, compared to general care. Having delivered significant improvement programmes in both settings within IMPOWER, our reflections outline how, while there are some similarities, there are also key differences that must be taken into account for effective delivery in the mental health space:

What’s different

• Although mental health inpatient settings support lower numbers of people than general acutes, the complexity of peoples’ needs is almost always significantly higher. This increased acuity of need can make care and discharges from mental health wards feel very different: although incredibly important, perceptions and bureaucracy around words like ‘safe’ and ‘risk’ often add complexity to discharge, which can ultimately be detrimental to people on their journeys to recovery.

• There is ambiguity between Trusts, local authorities and ICBs on roles and responsibilities – which can make practical delivery, as well as accountability, very difficult.

• The weighty role of Responsible Clinicians, especially relating to treatment and eventual discharge, can make it difficult to share risk across systems in a truly collaborative and effective way.

• Co-production and the voice of the person can be even harder to build into care and discharge planning and service design. This is especially true if someone may not have capacity to consent, which can create confusion around how to best provide person-centred care.

• The Department for Health and Social Care’s (DHSC’s) statutory discharge guidance, tailored to mental health, is a helpful framework to understand person centred-, system-wide performance, and identify priority areas for change.

What’s similar

• Barriers to discharge (e.g. housing, organising ongoing support, allocation of a social worker etc.) tend to be similar in general acutes and mental health hospitals, though with different nuances.

• Focusing on frontline behaviour change works in delivering both swift and sustainable impact.

• Starting small, testing, learning and scaling is an effective way to building whole-system resilience. At IMPOWER we call this our ‘theory of change’.

• Despite dedicated mental health commissioning being commonplace in local authorities and ICBs, commissioning isn’t consistently playing its full role in keeping people well, neither by preventing people from experiencing mental ill health, nor supporting people immediately before or after inpatient stays.

At IMPOWER, we know that sustainable mental health systems can only be created and developed by putting local people, and systems, right at their heart. The time for action is now.