DCP response to new figures on readmission to mental health facilities

A freedom of information request by Dr Rosena Allin-Khan MP has revealed figures from NHS mental health trusts in England showing that last year, almost 5,000 people (children and adults) were readmitted to a mental health facility within a month of leaving.

In all, 3,381 patients were readmitted within 30 days of their discharge by 35 of the 54 specialist mental trusts in England during 2022-23. Extrapolating those figures to all 54 trusts suggested an estimated 4,927 people were readmitted within a month, she said.

Also, in 2022-23, 1,972 people were readmitted by 36 trusts within a week of discharge – something NHS mental health services accept should never happen. Extrapolation of those figures to the 54 care providers shows that an estimated 2,794 people returned as an inpatient within seven days

In response to these figures, the Division of Clinical Psychology has issued the following statement:

It is vital that the lived experience of those experiencing services, along with those delivering services, is brought to the attention of the public and discussed with policymakers.

Increased readmission rates are a multifaceted problem. It is not just an issue with mental health services, but health and social care more generally. One overarching factor is the need for increased funding as demand outstrips capacity. Another overarching factor is the need for a focus on trauma informed care. Psychologists are well placed to support a trauma informed approach which reduces readmissions and improves relationships.

Psychological support in both acute and community settings has been shown in research to reduce readmissions. The BPS has published guidance on the significance of psychological assessment, formulation and a range of psychological interventions to support recovery in acute settings as well as improving trauma informed care and wellbeing of staff. There is key information on the necessary psychological workforce to deliver such work. However, adequate staffing is often not achieved due to funding as well as recruitment and retention issues.

The lack of adequate psychological, and other therapeutic interventions available mean that people are discharged when the severity of their symptoms decrease and not when they have sufficiently recovered. There is often inadequate follow up care available following discharge to support further recovery in the community.

Unfortunately, two important indicators for readmission to hospital are previous admissions and length of stay, and thus people become stuck in a cycle which can reinforce difficult relational experiences and trauma. Some people with more complex presentations or multiple risk factors require additional support which frequently is not available. Those with repeated admissions are often those who have accessed services from a younger age. The difficulties and delays for children accessing mental health care has impacted on the number requiring adult services when they turn 18. Furthermore, communities affected by health inequalities, are more likely to be readmitted Nazroo et al, 2020; Lin et al, 2020).

Therapeutic interventions in the community, including family interventions, are helpful in reducing readmissions, along with crisis and home treatment teams and in-reach to in-patient services for community staff. "Psychological services are in demand and, although the psychological workforce in secondary care services is growing, it is not able to meet demand. It is often those in crisis or require additional support to build relationships with services that are not able to access a service when they need it. There is a lot of attention on increasing access to psychological therapies across secondary care within the NHS Community Mental Health Transformation of secondary care with increased roles and improved training routes. This is very welcome. However, there is a real challenge for funding these posts without adequate additional funding available and without structures to support these roles. Often those with repeated admissions would have fallen under the care of assertive outreach teams due to their complexity and longer-term needs, but most of these teams across the country are no longer funded since funding is led by shorter term outcomes.  

In England, the NHS Long Term Plan highlights the importance of collaboration between different agencies. When individuals receive care from multiple agencies such as supporting housing providers, third sector agencies and specialist services, liaison and coordination is required, which can be challenging with stretched services. Of particular significance is both neurodevelopmental support and dual diagnosis (alcohol and substance misuse) support.

Neuro-developmental services are not able to manage demand at this time, and often those with multiple admissions require neurodiversity assessments and additional support, which is not available.

In addition, dual diagnosis services have not been adequately supported ever since they were taken out of NHS core provision, and thus there is often a lack of coordination of care between addiction and mental health elements of people's care. 

Given all the difficulties detailed above, it is not surprising that those with multiple admissions often have difficult relationships with services. Any solutions need to attend to the relationships with clients and require a person-centred, trauma informed approach. Having one admission can be traumatic for an individual and their family, thus having multiple admissions only adds to the experience of trauma and lasting impact of this trauma.

There are various pilots targeting readmission rates. We would support those that bring hope and avenues for change while focusing on the relationship, as well as working collaboratively with the multiple agencies in the system, for example open dialogue which are being trialled across the UK.