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NHS England commissioned databases for research (including Trip for clinical questions and evidence)

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NHS England commissioned databases for research (including Trip for clinical questions and evidence)

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NHS England | Workforce, training and education | Knowledge and Library Services

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Overview | Workforce, training and education | NHS England

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Nationally purchased content comprises a range of electronic databases, journals, ebooks, British Medical Journal (BMJ) Best Practice, and Trip Pro.

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Your Notts Directory (all support services/ community resources/ personal assistants/ food support/ SEND/ childcare costs/ work and volunteering/ money and finance)

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Your Notts Directory (all support services/ community resources/ personal assistants/ food support/ SEND/ childcare costs/ work and volunteering/ money and finance)

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Learn how local organisations can submit activities, events, or support services to be featured on Your Notts Directory.

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The Casey Commission- Independent Commission on Adult Social Care (social care change/ reform)

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The Casey Commission- Independent Commission on Adult Social Care (social care change/ reform)

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Independent Commission on Adult Social Care

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Practice Capabilities Framework 2026- guidance

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Practice Capabilities Framework 2026- guidance

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The capabilities framework sets out progression and developments for forensic mental health social workers.

The forensic social work capabilities framework is designed to build upon the generic requirements set out in the professional capabilities framework (PCF) for social workers.

The new capabilities, placed within the existing domains of the PCF, outline a framework for post-qualifying progression and development for social workers practising within forensic mental health settings.

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Forensic mental health social work: capabilities framework

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The capabilities framework sets out progression and developments for forensic mental health social workers.

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NHS Social Work Leads Network Identity Statement 2026

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NHS Social Work Leads Network Identity Statement 2026

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BASW The Contribution of Social Workers to multi-disciplinary practice 2026

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BASW The Contribution of Social Workers to multi-disciplinary practice 2026

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The contribution of social workers to multi-disciplinary practice BASW June 2026

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Gavin Moorghen

Regional Engagement Lead (Midlands)

gavin.moorghen@socialworkengland.org.uk

1 North Bank, Blonk Street, Sheffield, S3 8JY

Tel: 01147003561

My usual working days are Mon-Fri

Pronouns I use: He/him

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CAMHS Academy (Isle of Wight- training and e-learning/ peer support)

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CAMHS Academy (Isle of Wight- training and e-learning/ peer support)

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Commons Report on Community Mental Health 2025 (including recommendations for everyone with serious mental ill health to have access to mental health social work)

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Commons Report on Community Mental Health 2025 (including recommendations for everyone with serious mental ill health to have access to mental health social work)

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Working Together to Safeguard Children (2026 update- safeguarding)

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Working Together to Safeguard Children (2026 update- safeguarding)

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Research in practice complex capacity assessment guidance (MCA/ finance/ informal admission/ CTO/ self-neglect/ use of alcohol or drugs/ domestic abuse/ Prader Willi Syndrome)

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Research in practice complex capacity assessment guidance (MCA/ finance/ informal admission/ CTO/ self-neglect/ use of alcohol or drugs/ domestic abuse/ Prader Willi Syndrome)

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Using AI for CPD and Trust AI guidance (Artificial intelligence/ training/ registration standards)

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Using AI for CPD and Trust AI guidance (Artificial intelligence/ training/ registration standards)

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AI update for completing CPD Trust guidance

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Child Outcomes Research Consortium- using outcome measures effectively with neurodivergent children (autism/ ASD/ ADHD/ practice guidance/ research)

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Child Outcomes Research Consortium- using outcome measures effectively with neurodivergent children (autism/ ASD/ ADHD/ practice guidance/ research)

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Making Mental Health Services Better for Neurodivergent Children and Families: A Practical Guide for Professionals and Parents (autism/ ASD/ ADHD)

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Making Mental Health Services Better for Neurodivergent Children and Families: A Practical Guide for Professionals and Parents (autism/ ASD/ ADHD)

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2025_OSF_A Practical Guide for Parent and Professionals_NW.pdf

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Our goal in this easy read guide is to make sure that every neurodivergent child and their families gets the right support at the right time. With the help of 38 people sharing their experiences, this easy read guide aims to help mental health professionals to work together with neurodivergent children and their families.

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The Nottingham Enquiry (public enquiry/ Valdo Calocane)

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The Nottingham Enquiry (public enquiry/ Valdo Calocane)

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Terms of Reference – The Nottingham Inquiry

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A public inquiry into the devastating Nottingham attacks in June 2023.

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British Future (social cohesion/ anti racist/ oppressive practice support)

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British Future (social cohesion/ anti racist/ oppressive practice support)

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"British Future works to understand public attitudes and inform debates on issues that can often seem noisy and polarised. We listen to people's views, finding common ground and offering constructive solutions - building consensus for reforms to immigration and integration policy that can work for all of us."

Sunder Katwala, Director

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"British Future works to understand public attitudes and inform debates on issues that can often seem noisy and polarised. We listen to people's views, finding common ground and offering constructive solutions - building consensus for reforms to immigration and integration policy that can work for all of us."

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Employment support within LMHT's for over 18's (work- please call the relevant LMHT and ask for their employment specialist)

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Employment support within LMHT's for over 18's (work- please call the relevant LMHT and ask for their employment specialist)

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Nottinghamshire Healthcare NHS Foundation Trust

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Nottinghamshire Healthcare NHS Foundation Trust

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Employment support services for people using secondary mental health services

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NHS 10 year Health Plan (Long Term Plan) 2025

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NHS 10 year Health Plan (Long Term Plan) 2025

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10 Year Health Plan for England: fit for the future

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Sets out the government’s 10 Year Health Plan for England.

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Directorate lead for Social Work= Diane Hull

Associate Director of Social Work= Kelly Kaiser.

As the professional lead for social work I'm able to provide consultation and leadership across the Trust. I link in with the National PSW network, NHS Social Work Leadership network, AMHP Leads forum as well as NottsHC clinical, strategic, operational and professional lead networks. Please get in touch if I can be of any help! 07920 407007.

AMH=

AMH Social Work Lead- currently vacant, expansion and recruitment to this role currently being explored.

Maja Henek - Crisis Care Practitioner, Social Worker. Mid and North Notts CRHT.

Molly Fleischer - Social worker, Broxtowe and Hucknall LMHT

OPCU=

Kelly Kaiser- Consultant Social Worker and Approved Clinician. AMHP/ BIA. Cherry Ward, Highbury Hospital.

Forensics=

Hayley Frame= Head of Forensic Social Care

James Liddement= Social Work Manager at Rampton

Nicola Gray= Social Work Manager at Rampton

Kirsty Broughton: Senior Forensic Social Worker, Mental Health Directorate, Rampton Hospital.  Also Practice Mentor Assessor, Practice Educator and AMHP.

Emily Doherty: Senior Forensic Social Worker, National High Secure Learning Disability Service, Rampton Hospital

Offender Management=

Hayley Frame- Professional Lead for Offender Management

Safeguarding=

Amanda Garnett- Trustwide Service Manager for Safeguarding & Public Protection.

Part of the Trustwide Safeguarding Team, providing safeguarding leadership, advice & guidance to all Trust staff.

Can be contacted via the Safeguarding Team or on 07917 558747

Perinatal Social Worker= Alesha Parks

CAMHS:

Angela Walker= Service Manager, Specialist CAMHS

CAMHS Inpatient

Simon Robinson = Inpatient Social Worker at Hopewood CAMHS unit.

Janga Singh - Senior Social Worker with the East Midlands Forensic CAMHS team.  Based at 70 Portland Street.

CAMHS Crisis & Liaison

Satvinda Rai - Senior Specialist Practitioner (Social Worker/AMHP)

CAMHS COMMUNITY NORTH
Ryan Smith - Clinical Lead (Registered Social Worker & Practice Educator)

Karl Phillips - Systemic Family Therapist (Registered Social Worker)

Hannah Everitt - CBT & EMDR Therapist (Registered Social Worker)

CAMHS COMMUNITY WEST
William Mclennan - Senior Specialist Practitioner (Registered Social Worker/PEPs 1 Practice Educator)

CAMHS COMMUNITY SOUTH

Michael Bullett - Clinical Lead

SSD/ IDD=

Mental Health Legislation Team =
Dannielle Wilks = Mental Capacity Act Senior Practitioner. Best Interests Assessor (BIA).

Primary Care Network Mental Health Practitioner:

Livia Brown - as part of the city south LMHT, working with patients with moderate to severe mental illness in their primary care setting within Clifton and the Meadows

Amy Hubbard - as part of Newark and Sherwood LMHT, working with patients with moderate to severe mental illness in a primary care setting within the Sherwood half of the district

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Watchdog escalates Social Work England fitness to practise concerns to cabinet ministers - Community Care

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Professional Standards Authority writes to Bridget Phillipson and Wes Streeting over ongoing Social Work England fitness to practise concerns

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Anchor housing for older adults (Extracare/ warden/ supported/ over 55's independent living)

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Anchor housing for older adults (Extracare/ warden/ supported/ over 55's independent living)

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Anchor is England's largest provider of specialist housing and care for people in later life, offering care homes, retirement villages, and retirement homes.

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The Furniture project (cheap furniture/ hardship/ white goods/ fidges etc)

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The Furniture project (cheap furniture/ hardship/ white goods/ fidges etc)

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Framework Housing (County only/ homelessness support)

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Framework Housing (County only/ homelessness support)

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How your money helps

Your donations empower us to help people on your behalf. Here's an example of what we do with that money.

to fund a personal development session for a young care leaver to help them move towards employment

to provide a mental health support session with Framework's clinical psychologist for someone dealing with trauma

to enable a rough sleeper two nights in a hotel

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Framework Housing Association | For Your Future

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We deliver housing, health, employment, support and care services to people with a diverse range of needs across the midlands & the north of England.

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Working Together to Safeguard Children 2026 summary of changes

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Working Together to Safeguard Children 2026 summary of changes

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Working together to safeguard children 2026: summary of changes

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We have clarified that the guidance applies to all children, including:

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Fitness to practise- Dishonesty (Nottinghamshire Healthcare NHS Foundation Trust ) 04.02.25

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ADASS/ LGA Framework for Achieving Excellence in Mental Health Discharge guidance

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ADASS/ LGA Framework for Achieving Excellence in Mental Health Discharge guidance

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A framework for achieving excellence in mental health discharge

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This practical guidance draws on extensive engagement with front line teams, statutory guidance and mental health discharge operational models that are working well across the country.

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DHSC Statutory Guidance on discharges from mental health inpatient settings January 2024 

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DHSC Statutory Guidance on discharges from mental health inpatient settings January 2024 

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Executive summary

It is vital that organisations across the health system work together to ensure effective discharge planning and the best outcomes for people who are discharged from hospital, and that people and their chosen carers are fully involved in the process. This guidance gives organisations across the health and care system greater clarity about what the 'duties to cooperate' (under sections 72 and 82 of the NHS Act 2006) mean in practice in the context of discharge from all mental health and learning disability and autism inpatient settings for children, young people and adults. It aims to share best practice in relation to how NHS bodies and local authorities can work closely together to support the discharge process and ensure the right support in the community. It provides clarity in relation to responsibilities in the discharge process, including funding responsibilities. In addition, the guidance incorporates best practice in relation to patient and carer involvement in discharge planning.

The section 'Principles for how NHS bodies and local authorities should work together' sets out key principles for how NHS Bodies (including NHS trusts, NHS foundation trusts and integrated care boards ( ICBs)) and local authorities should work together for effective discharge planning from all mental health inpatient services:

principle 1: individuals should be regarded as partners in their own care throughout the discharge process and their choice and autonomy should be respected

principle 2: chosen carers should be involved in the discharge process as early as possible

principle 3: discharge planning should start on admission or before, and should take place throughout the time the person is in hospital

principle 4: health and local authority social care partners should support people to be discharged in a timely and safe way as soon as they are clinically ready to leave hospital

principle 5: there should be ongoing communication between hospital teams and community services involved in onward care during the admission and post-discharge

principle 6: information should be shared effectively across relevant health and care teams and organisations across the system to support the best outcomes for the person

principle 7: local areas should build an infrastructure that supports safe and timely discharge, ensuring the right individualised support can be provided post-discharge

principle 8: funding mechanisms for discharge should be agreed to achieve the best outcomes for people and their chosen carers and should align with existing statutory duties

In the section 'Specific guidance for particular people in hospital' there is guidance for groups of people including:

children and young people

people with a learning disability and autistic people

a person with dementia

people admitted to forensic inpatient settings

people experiencing, or at risk of, homelessness

people with co-occurring mental health and drug and/or alcohol conditions

a person with no recourse to public funds

The final section of the guidance sets out roles and responsibilities of organisations in the discharge process, including commissioners of services, NHS trusts and local authorities. In the annex, there is additional statutory guidance on how budgets and responsibilities should be shared to pay for section 117 aftercare ( Mental Health Act 1983).

About this guidance

This guidance is intended for NHS bodies in England including NHS England, special health authorities, NHS trusts, NHS foundation trusts and ICBs, as well as local authorities in England. These organisations will henceforth be referred to as NHS bodies and local authorities.

Section 82 of the National Health Service Act 2006

Section 82 of the National Health Service Act 2006 ('the NHS Act 2006') requires NHS bodies (on the one hand) and local authorities (on the other) to co-operate with one another in order to secure and advance the health and welfare of the people of England and Wales. Section 82 requires that NHS bodies and local authorities have regard to guidance issued by the Secretary of State on the discharge of the duty to co-operate.

To give greater clarity about what this duty means in practice, the Health and Care Act 2022 provides a power by way of an amendment to the NHS Act 2006 for the Secretary of State to issue guidance to NHS bodies and local authorities on what cooperation under Section 82 NHS Act 2006 should entail. NHS bodies and local authorities are required to have regard to such guidance.

This guidance, where it relates to the duty to co-operate, is issued by the Secretary of State under section 82 of the NHS Act 2006.

Section 74(2) of the Care Act 2014

Section 74 of the Care Act 2014 states that where a relevant trust is responsible for an adult hospital patient and considers that the patient is likely to require care and support following discharge from hospital, the relevant trust must, as soon as is feasible after it begins making any plans relating to the discharge, take any steps that it considers appropriate to involve the patient and the carer of the patient.

Under this duty, a 'carer' is defined as an individual who provides or intends to provide care for an adult, otherwise than by virtue of a contract or as voluntary work.

In performing this duty in accordance with section 74 of the Care Act 2014, a relevant trust must have regard to any guidance issued by NHS England. This guidance, where it relates to the duty under section 74 of the Care Act 2014, is issued by NHS England.

How this guidance applies to NHS bodies and local authorities

This guidance has been issued under section 82 of the NHS Act 2006 where it relates to how NHS bodies (including NHS England, special health authorities, NHS trusts, NHS foundation trusts and ICBs), and local authorities should work together to plan and deliver discharge and has been published by the Secretary of State for Health and Social Care. This guidance is statutory in relation to discharge from all mental health inpatient settings, including forensic inpatient settings, those specifically for people with a learning disability and autistic people and those for children and young people. This applies to people being discharged into the community, whether to their home or other accommodation in the community including temporary step-down services, supported accommodation or a care home. Transfers within specialised commissioned services are not in scope of the guidance. This guidance applies to NHS bodies and local authorities exercising health and social care functions for children and adults in England and should be used to inform local service planning and delivery. Even though the statutory duty to have regard to this guidance applies to NHS bodies and local authorities and not the independent sector, this guidance is applicable to independent providers. Commissioners of inpatient services should ensure that all mental health inpatient providers are aware of this guidance, including those in the independent sector. Commissioners will be expected to have regard to this guidance when commissioning services from the independent sector.

Where the guidance refers to how to involve adult inpatients and their carers in discharge planning, this is issued by NHS England under an amendment to section 74 of the Care Act 2014 made in section 91 of the Health and Care Act 2022. This is mostly set out in principle 1 and principle 2, although there are other references throughout the guidance. Given this duty to involve inpatients and their carers in discharge planning applies to adults, the guidance is non-statutory guidance where it makes reference to how children and young people and their parents, other family members and carers are involved in discharge planning.

There is information throughout this guidance that may also be of benefit to integrated care partnerships ( ICPs), care providers, housing services and providers, and voluntary, community or social enterprise ( VCSE) organisations. There is separate statutory guidance for adults being discharged from NHS acute hospitals, NHS community hospitals and virtual wards.

The review of the Mental Health Act highlighted a lack of clarity over who is responsible for arranging the provision of care for people subject to section 117 aftercare under the Mental Health Act. This is often cited as a reason for delays in making arrangements for a person's care and support in order to facilitate hospital discharge in a timely manner. Statutory guidance, 'National guidance on how budgets and responsibilities should be shared to pay for section 117 aftercare' (Mental Health Act 1983) is provided as an annex to this document to provide greater clarity on how budgets and responsibilities should be shared to pay for section 117 aftercare.

This guidance should be considered alongside NHS England guidance on Acute Inpatient Mental Health Care for Adults and Older Adults and Quality Transformation Programme-Mental Health and learning disability and autism Inpatient commissioning framework.

For children and young people, the guidance should be considered alongside the framework for supporting children and young people (CYP) with mental health needs in acute paediatric settings.

For people with a learning disability and autistic people, see Safe and wellbeing reviews: thematic review and lessons learned.

Principles for how NHS bodies and local authorities should work together

This section sets out key principles for how NHS bodies and local authorities across adults and children's services should work together to support people to be discharged from all mental health inpatient services, including mental health inpatient services for people with a learning disability and for autistic people. See the section 'Specific guidance for particular people in hospital'. Where we refer to 'people', this means all adults, young people or children who are being discharged from a mental health inpatient setting, unless otherwise specified.

In this guidance, 'carers' or 'chosen carers' are defined as all family members, friends and others who are providing unpaid care to the person being discharged. This includes (but is not limited to) adult carers, young carers, young adult carers and parent carers. For children and young people, this includes parents and guardians.

In this guidance, 'local areas' is used as a collective term for NHS bodies (including ICBs, NHS trusts and NHS foundation trusts) and local authorities exercising functions in England.

Principle 1

Principle 1: individuals should be regarded as partners in their own care throughout the discharge process and their choice and autonomy should be respected.

The choice and autonomy of the person should be paramount throughout the discharge process. The person should be at the centre of planning for their own discharge and care and treatment plans that support this, and what matters most to them should be understood and recorded. They should be supported to understand the process for assessing their needs and how they can engage. Their views and choices should be listened to, actively explored and respected, and all discharge decisions must be informed by the person's choices and preferences. There are lots of resources about person-centred support and planning that can help staff to do this, including in relation to the Mental Capacity Act: Care planning, involvement and person-centred care and Introduction to Person-centred Planning Tools.

As soon as discharge planning begins, the inpatient team should ask the person how they would like to be involved in discharge conversations and whether they would want someone else to support them with this. When the person does not wish to be involved in discharge planning, staff should seek to understand the reason for this, and whether they would still want to be involved in some aspects of their discharge planning. The person should be given regular opportunities to update their preferences in relation to their involvement in discharge planning and to choose ways they might engage with the process informally or through others. If the person does not wish any involvement, staff should ensure that their views are represented as much as possible. This may include consulting family members, their chosen carers or advocates, where consent is given as appropriate, and consulting an advanced choice document if previously recorded by the person.

For children and young people, it is important to involve parents or guardians and their wider network of support (which may include carers and other relevant family members) in discharge planning. If a child or young person does not wish to engage in decision making, the parents and network around them will continue to work together while continuing to involve the child or young person as much as possible.

A personalised care and support plan, as a result of a 'what matters to me' conversation, should be prepared and available to support discharge with input, where relevant, from family members, chosen carers and relevant professionals. For children and young people, this must include parents or guardians, carers, any other relevant family members and any professionals in ongoing care, as appropriate. Discharge planning should consider all the persons care and support needs, including their housing needs.

The principles of the Mental Capacity Act ( MCA) 2005 should always be applied to support people with decision making, including any decisions in relation to discharge planning. The MCA 2005 applies to those age 16 or over. However if a child who is below the age of 16 is considered ' Gillick competent', they may be able to contribute to decisions around discharge planning. For more information on mental capacity considerations see Annex A.

In some cases, decisions may be made that go against the wishes of the patient, for example the patient's preferred discharge destination may not be possible. In these cases, sufficient information must be provided to ensure the person understands the rationale and alternative options should be explored. The person should also be made aware of how they can challenge any decisions.

Reasonable adjustments are a legal requirement under the Equality Act 2010 to make sure health services are accessible to disabled people and should therefore be put in place where needed. This includes when supporting people with discharge planning. All written information should be provided in an accessible format, depending on people's communication preferences. Personal information should be shared in accordance with organisational policies and procedures, and the law protecting the right to privacy. For example, this may involve:

providing information in written and verbal formats

large print, braille and easy read formats

using augmentative and alternative communication or video clips and visual diagrams to aid interpretation

drawing on the support of people who know the person's communication preferences

For children, developmentally appropriate language should be used.

People receiving inpatient care should be given the opportunity to access an independent advocate to represent and support them where eligible, and reasonable adjustments should be made to ensure that the person is able to take up the offer of advocacy. This could include an independent mental health advocate ( IMHA) where the conditions apply (if they are detained or transferred under certain provisions of the Mental Health Act 1983 or subject to section 17 leave, a Community Treatment Order ( CTO) or guardianship), an Independent Mental Capacity Advocate ( IMCA) (in certain cases where the person lacks capacity to make a decision concerning serious medical treatment or the provision of long term hospital, care home or residential accommodation) or a Care Act advocate (in certain cases where a Care Act assessment, care planning decision or safeguarding enquires are being undertaken). A decision not to instruct an advocate should be reviewed at regular points in case the person's situation changes and the duty to provide an advocate applies. Everyone who is detained or transferred under the Mental Health Act (except certain short-term detentions) has a statutory right to access an IMHA, as do those subject to section 17 leave, a CTO or guardianship. They should be made aware of their right to an IMHA at the point of admission to hospital or when being placed under the relevant powers and should be supported to access this service. IMHAs can help people to understand their rights under the Mental Health Act, as well as support them to participate in decisions in relation to their care and treatment and represent their views and interests. This may include decisions in relation to discharge. The person should be supported to access legal advice if they wish to.

People should also be supported to access support from peer support workers in the discharge process wherever possible. They should have a diverse range of experiences and appropriate cultural competency, in line with the definition by the Care Quality Commission.

Principle 2

Principle 2: chosen carers should be involved in the discharge process as early as possible.

Processes should be in place to identify any carers, including family members and young carers, at the point of admission (or before, where possible) and this should be recorded on the person's electronic hospital record. The person must be asked who they would like to be involved in discharge planning and they should be given opportunities to update their preferences, including the types of information they are happy to share with their chosen carer or carers. For children and young people under 18, this should include those with parental or guardian responsibility. For a child who is looked-after by a local authority, this must include the local authority, including the child's social worker, and should also include the child's foster carers or the appropriate persons in the children's home where the child is placed. Further statutory guidance, Promoting the health and wellbeing of looked-after children, should also be followed. For a young person aged 16 to 17 who is a care leaver, their social worker should be involved. For a care leaver aged 18 to 24, consent should be sought to involve their personal adviser if the young person has one.

Staff must check that any chosen carers are both willing and able to take on the role of supporting the person. With consent from the person, they should be asked how they would like to be involved in discharge planning conversations and about any support they may need to participate. Inpatient teams should accommodate work and other responsibilities of carers as much as possible, so that they are able to attend discharge planning meetings. Reasonable adjustments should be put in place to support individuals who may have communication impairments as a result of a disability.

Carers should be offered culturally appropriate support when they are identified. This may include being signposted to local carers' support services, as well as referrals to appropriate voluntary services which may be able to offer support. According to the Care Act 2014, local authorities are required to undertake a carer's assessment for any unpaid carer who appears to have a need for support, and to meet their eligible needs on request from the carer. This is an opportunity to record the impact caring has on the carer and to look at the carer's needs, including whether they are willing or able to continue caring. If a carer is assessed as having needs that are eligible for support under the Care Act, then the local authority has a legal duty to meet these needs on request from the carer and to draw up a support plan with the carer setting out how these needs will be met. In addition, under the Children Act 1989, there is a duty for local authorities to assess the needs of parent carers dependant on the appearance of need and/or if a parent carer requests one, and decide whether it is appropriate to provide services to support the parent carer. A 'parent carer' is defined as a person aged 18 or over who provides or intends to provide care for a disabled child for whom the person has parental responsibility.

The local authority should be notified if someone is a young carer (under the age of 18) and must carry out an assessment in accordance with their responsibilities under section 17 of the Children Act 1989. As outlined in the Children and Families Act 2014, young carers should be offered the appropriate support that avoids excessive or inappropriate caring.

Staff members should be alert to any indications that a person or their carer, including a parent of a child or young person, is being abused, or may be abusive or neglectful. Concerns must be raised via local safeguarding processes and safeguarding protocols should be followed. Staff should be aware of how to raise safeguarding concerns regarding any adults or children or young people they come into contact with, in line with duties under the Care Act 2014 and the Children Act 2004 and the statutory guidance on care and support and safeguarding children.

Good practice: 'Triangle of Care' membership scheme

The ' Triangle of Care' is a carer engagement approach for mental health services that ensures appropriate carer inclusion throughout the person's care journey, including discharge planning.

The Triangle of Care membership scheme was developed by the Carers Trust to address the ask from carers that they need to be listened to and consulted more closely. It applies to both adult carers and young carers. The scheme recognises providers who have committed to change through self-assessment of their existing services, and ongoing action planning to ensure the Triangle of Care standards are achieved and maintained. The Triangle of Care path follows a 3-tier accreditation system. Providers that successfully complete each stage receive accreditation through a star system. Attainment of stars does not reflect that work is complete but recognises that a trust is proactively working towards a more inclusive culture for carers. Many NHS mental health trusts are members of the scheme and there is potential for all health and social care settings to adopt the Triangle of Care.

Principle 3

Principle 3: discharge planning should start on admission or before, and should take place throughout the time the person is in hospital.

On admission, or before where possible, inpatient teams should agree a clear purpose for the admission and an estimated discharge date for when this will be achieved. This work should be done with the person at the centre of discharge planning, their chosen carer or carers (including parents and guardians for children and young people) and relevant professionals. This discharge plan should then be reviewed with the person at regular intervals during the admission. This is to give as much time as possible for understanding what really matters to the person, for appropriate post-discharge support to be put in place and the person to be supported with the transition, without causing delay.

Processes should be in place to identify people who may be at risk of a delayed discharge (for example, due to social care or housing needs) at the point of admission or before. Factors that could delay discharge (for example, the need for suitable housing or accommodation and/or a care package) should be reviewed at regularly agreed intervals throughout the inpatient stay and proactive action should be taken to address any barriers. People who are eligible to section 117 aftercare and/or a personal budget (for social care and support needs) or a personal health budget ( PHB) should be identified on admission. People who are eligible to section 117 aftercare have a legal right to a PHB.

Services and professionals that are already involved in the person's care should be identified at the point of admission. A full assessment of the person's needs should take place to inform the person's care and treatment plan. This should consider all the person's care and support needs including their psychological, physical health, pharmacological, social, cultural, housing and financial needs, environmental or sensory needs, and communication preferences. What matters to the person should be understood and documented and any additional care and support that may be required post-discharge, including housing, should be identified as soon as possible. For children and young people, considering educational needs is essential, so that the relevant educational support can be put in place during and after the admission. For young people who are transitioning from children to adult's services, professionals involved in their care should ensure that they are supported with this transition in a sensitive and timely manner (see section 3 for considerations for children and young people). If the person is a parent or unpaid carer, consideration should be given to the needs of their family, and a referral made as appropriate to the local authority early help team or children's social care team.

Assessments should take place early on during the person's stay in hospital with regular checks on progress, allowing for regular review of the estimated date of discharge. This may include making arrangements for the local authority to carry out an assessment under the Care Act 2014, an assessment under the Children Act 1989 and/or section 47 National Health Service and Community Care Act 1990 in regard to section 117 aftercare entitlement and right to a personal health budget. A range of options for post-discharge support should be considered, dependant on the person's needs, which may include community-based support provided by the voluntary and community sector.

For autistic children, young people and adults, and those with a learning disability, there should be regular Care (Education) and Treatment Reviews ( C(E)TRs) in line with NHS England's guidance Dynamic support register and Care (Education) and Treatment Review policy and guide (see further information in the section on 'People with a learning disability and autistic people').

Under the Homelessness Reduction Act 2017, specified public bodies, including hospitals in their function of providing inpatient care and social service authorities (both adult and children's), have a duty to refer people who they think might be homeless, or at risk of becoming homeless within 56 days of admission, to local housing authorities. Local housing authorities and public authorities are encouraged to put arrangements in place to support joint working, and it is good practice for public authorities to plan with the local authority using agreed protocols (see guide to the duty to refer). Identification of a person's housing status and referral to the local housing authority, if required, should happen as early as possible during an inpatient stay and should form a key part of the discharge planning.

People's choice around their housing options on discharge should be explored and respected, taking into account what the person needs from their accommodation and any risks associated with their existing or preferred accommodation. To support this, and especially if the person is unlikely to be able to return to their former home on discharge from hospital, a housing needs assessment should be completed in consultation with the person and those supporting them, which may include professionals such as occupational therapists, social workers and representatives of the housing provider, if this has been identified. This assessment should include consideration of any sensory or environmental needs which the person may have, as well as other needs, such as to live near amenities like public transport and health services, and any risks which will need to be managed in the community to enable them to do this. The housing needs assessment would then inform a personal housing specification, if required, which would include any design requirements or home adaptations that may be needed.

Similar joint working and planning should also be undertaken with local housing authorities if people need home adaptations to enable them to continue to live safely and independently at home after discharge. People of all ages and tenures may be eligible for a Disabled Facilities Grant that helps meet the cost of adaptations for those on low incomes, subject to a needs assessment, means test and eligibility criteria. This includes people with a mental health condition, autistic people, people with a learning disability or cognitive impairment, like dementia.

Principle 4

Principle 4: health and local authority social care partners should support people to be discharged in a timely and safe way as soon as they are clinically ready to leave hospital.

Relevant health and social care professionals should work with the multidisciplinary inpatient team throughout the inpatient stay to support the person to be discharged in a safe and timely way. For children and young people, this should include working closely with education settings. This reduces the risk that people spend longer than necessary in an inpatient setting.

A person is considered Clinically Ready for Discharge (CRFD) when the multi-disciplinary team ( MDT) conclude that the person does not require any further assessments, interventions and/or treatments, which can only be provided in an inpatient setting.

Below are the 3 key criteria which need to be met before the multi-disciplinary team on an inpatient ward can make this decision:

there must be a clear plan for the ongoing care, support and housing that the person requires after discharge, which covers their pharmacological, physical health, psychological, social, cultural, education, housing and finances, and any other individual needs or wishes

the MDT must have explicitly considered the person and their chosen carer's views and needs about discharge and involved them in co-developing the discharge plan

the MDT must also have involved any services external to the provider in their decision making for example social care teams, where these services will play a key role in the person's ongoing care. This should include clarifying any procedural and/or legal duties of the local authority to put services in place

Once these criteria are met, the person is clinically ready for discharge, and this should be recorded as such on the electronic patient record (EPR) systems. However, this does not necessarily mean the person can be immediately discharged. Once a person is clinically ready for discharge, the inpatient team should be satisfied that the right support is in place before discharge takes place. For example, the person must have suitable accommodation to be discharged to, an appropriate time of day identified, and necessary packages of care and support should be arranged.

In cases where there is disagreement regarding whether a person is clinically ready for discharge, NHS trusts should have a multiagency escalation process in place.

Principle 5

Principle 5: there should be ongoing communication between hospital teams and community services involved in onward care during the admission and post-discharge.

Discharge planning should involve organisations and professionals that will be involved in the person's care post-discharge. There should be a clear plan in place agreed collaboratively to ensure the person receives the right support post-discharge. This should be a multi-disciplinary, cross-organisational approach.

Throughout the inpatient stay, people should be supported to maintain links with family and friends, local health and social care providers, education, recreational activities and employment. This is both important for recovery and to help people to prepare for discharge. Where the person may be at risk of losing employment or education opportunities during the admission, they should be provided with advice and support to prevent this. Maintaining links with the person's local community is particularly important for people admitted to inpatient wards that are outside of their local area.

To support a person to be ready for discharge, hospital inpatient teams should discuss with the person how they can be supported with the transition, and how they can build on their strengths. For example, some people may benefit from individualised psycho-education sessions in line with National Institute for Health and Care Excellence (NICE) guidance, which may include their symptoms, relapse indicators and coping strategies. Depending on their individual needs, staff should signpost to other relevant support that may aid their recovery post-discharge, for example, employment, housing or benefits advice. For people detained or transferred under the Mental Health Act, section 17 leave should be used where appropriate to support people to be ready for discharge, with relevant family and professionals from other services involved in supporting the person as part of collaborative discharge planning.

Prior to the discharge date, a crisis and safety plan should be developed in collaboration with the person and their chosen carer or carers with input from relevant members of the multi-disciplinary team. Professionals involved in the person's care may also support the person to develop an Advance Choice Document, outlining the person's choices in treatment, if they are to be admitted to hospital again. With consent, relevant care plans, safety plans or personalised risk management plans should be shared with professionals that will be involved in their ongoing care. Advice and information about community, voluntary sector organisations and crisis services (including how to access support 24 hours a day, for instance, through all ages urgent mental health helplines) should be shared with the person and their chosen carers and families ahead of the discharge date, with appropriate consent. For children and young people, information may need to be shared with parents/guardians and other relevant family members without consent in some cases, depending on individual factors including level of risk.

The person, their chosen carer or carers and external services involved in the person's care should be informed of the expected date of discharge within 72 hours of their admission and any changes to this date and the reason for the change should be communicated as soon as the change happens. For people who have been admitted to a hospital that is at a distance from where they live, it is particularly important that the person's local services are involved in the discharge process and that the care plan and discharge plan is reviewed at regular intervals. For people eligible for section 117 aftercare, a section 117 discharge planning meeting should take place prior to discharge with relevant professionals involved.

There should be a collaboratively agreed plan in place that involves relevant organisations and professionals proactively communicating with the person and any chosen carer or carers and family members following the discharge date. This should have clear responsibilities and a plan to review the care in place. Plans should also be in place to review the needs of any chosen carer or carers, or other family members, including children.

The person and their carers should be aware of the process to raise any concerns with the care in place post-discharge, and how this should be resolved. For example, if the support in place is not meeting the needs of the person or the needs of their unpaid carer or carers.

For locally commissioned acute mental health inpatient admissions, inpatient teams should ensure that everyone receives a follow up meeting from their community mental health team, intensive support team (IST) or crisis resolution home treatment team within 72 hours of their discharge date in line with national standards. The person should be informed of the time and place of this before their discharge date, and this should be face to face if possible. With the person's consent, this should involve family and carers where appropriate.

Timely follow-up has been highlighted as a priority from patient groups and the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH), due to the increased risk of suicide following discharge from hospital. When supporting people who self-harm, teams should ensure they are adhering to NICE guidance on assessing, managing and preventing self-harm.

NHS trusts should work with the local authority and relevant voluntary and community sector and housing organisations to support individuals with multiple needs to effectively access and engage with post-discharge support. This includes people who are experiencing homelessness or at risk of homelessness. This could include liaising with housing teams to identify temporary housing where longer-term housing is being sought, or advice from the Department of Work and Pensions (DWP) to ensure that benefit entitlement is maximised for the duration of a hospital inpatient stay, minimising the risk of eviction from a person's existing home.

Principle 6

Principle 6: information should be shared effectively across relevant health and care teams and organisations across the system to support the best outcomes for the person.

NHS bodies and local authorities should have information sharing protocols in place to ensure there is a clear process and that information is shared between organisations across the health and care system in a secure and timely way.

Relevant information should be discussed and communicated with relevant parties in a timely manner, in accordance with local information sharing protocols and data protection legislation. This may include individuals and services who will provide ongoing support to the person. For example, care and treatment plans, including information about medication where relevant, should be shared with those who will be involved in post-discharge care, ahead of the discharge date. For people who have undergone assessments during their hospital admission, the inpatient team should make sure that the outcome of any assessment is shared with relevant professionals involved in onward care.

Key information about an individual's communication needs and preferences should be identified and recorded within an individual's care notes for all relevant professionals to be aware of and to take action to make sure that communication is tailored to the person's needs. For children and young people, this should take into consideration the communication needs of the child or young person and those with parental responsibility. With the person's consent, the name and contact of any carers, family members and/or independent advocates should also be recorded. In line with NICE guidance, discharge letters should be shared with the person's GP within 24 hours of discharge and their latest care plan should be sent to all professionals and carers involved in their care.

Principle 7

Principle 7: local areas should build an infrastructure that supports safe and timely discharge, ensuring the right individualised support can be provided post-discharge.

NHS bodies and local authorities should ensure there is senior strategic leadership and oversight of the discharge process to reduce unnecessary discharge delays and to make sure that discharge protocols are being followed. This may involve enabling regular meetings with system partners to unblock delays to discharge or regular multi-agency discharge events (note that you will need an NHS email to access this link) to identify solutions to discharge people when they no longer need to be in hospital.

Local protocols should be developed between NHS bodies, local authorities and other relevant partners to ensure clarity regarding each organisation's role and responsibility in discharge procedures. The local protocol should ensure that discharge planning starts as early as possible, with clear arrangements in place to ensure a collaborative multidisciplinary approach at all stages of the discharge process, including post-discharge (see section 4 for specific roles and responsibilities in the discharge process). There should be a named person responsible for discharge processes in each organisation across children and adult's services. The local protocols should include details of local funding arrangements between local authorities and NHS bodies. There should be an agreed escalation process where there are difficulties reaching an agreement in relation to discharge arrangements, including funding responsibilities.

Commissioners should make decisions that aim to meet the needs of local populations and ensure the sustainability of care and support, within existing budgets. This should be done in collaboration with relevant organisations, including the voluntary and community sector and care providers. This helps to provide the necessary provisions in the community so that people can be discharged as soon as they are clinically ready, with the right support in place that meets their needs. For example, this could include commissioning step-down services which provide a bridge between inpatient care and living independently in the community, or specialist supported accommodation for those requiring longer-term support. The option of supporting a person entitled to section 117 aftercare by means of accessing funded support with a personal health budget should also be readily considered (see Annex B below for national guidance on how budgets and responsibilities should be shared to pay for section 117 aftercare (Mental Health Act 1983)).

NHS organisations and local authorities should collaborate with relevant organisations, including the voluntary and community sector, drug and alcohol treatment providers, housing and homelessness providers, children's services and care providers in the commissioning process. This should include investing strategic and operational time to develop multi-disciplinary, cross-provider response for people who require coordinated support from multiple services (for example, homelessness or drug and alcohol treatment services) alongside mental health support post-discharge.

It is recognised that some people who have experienced long stays in hospital, including those in rehabilitation services, may choose to reside in the area where the hospital is located rather than their home area. Active discussions between ICBs should take place, to support the choice and wishes of the patient and their request for a different discharge location from their home area.

Case study: out of hospital care for people experiencing homelessness - reducing delayed discharges

Oxford Health NHS Foundation Trust were experiencing high numbers of delayed discharges from their mental health wards due to housing and homelessness issues. Many of the delays were long-standing, with some individuals becoming 'stuck' in hospital because housing options could not be identified for them for several reasons - including a perception of risk involved in housing them.

With the additional funding provided as part of DHSC's £16 million Out of Hospital Care programme for people experiencing homelessness, Oxford appointed an experienced Housing Options Officer co-located at the mental health hospital. This worker brought to the service extensive legal knowledge related to housing applications in addition to working knowledge of local housing and homelessness services to support ward staff in planning transitions from the hospital.

Oxford also opened a 3-bed step-down house specifically tailored to people leaving mental health wards. This included access to a clinical psychologist, social worker and community-based mental health workers. This service enables individuals to recover their mental health in the community when they no longer require acute care and facilitates services coming together collaboratively to support the individual.

Through implementing this additional hospital in-reach and step-down service they dramatically reduced occupied bed days by 89%. The overall cost saving to the NHS after the introduction of these services was estimated to be around £657,000 over 9 months. It is now rare for more than 2 people per week to experience delayed discharges, compared to an average of 14 to 18 people per week prior to service provision.

This service is driving real transformational change in Oxford, bringing together agencies to find new and positive ways of working together to support individuals and bolster system resilience.

Principle 8

Principle 8: funding mechanisms for discharge should be agreed to achieve the best outcomes for people and their chosen carers and should align with existing statutory duties.

NHS bodies and local authorities should ensure that funding mechanisms for discharge are agreed by all partners and should align with existing duties, including those under the Care Act 2014, Mental Health Act 1983, Children Act 1989, Children Act 2004 and the Children and Families Act 2014. For example, under the Mental Health Act 1983, local authorities and ICBs have a statutory duty to fund packages of care for those eligible for section 117 aftercare. If someone is entitled to section 117 aftercare, the person (and those with parental responsibility for children) should be aware of this, and notification of their admission should be made to the local authority. See Annex B for guidance on how budgets and responsibilities should be shared to pay for section 117 aftercare. In addition, ICBs and other relevant bodies have a duty to ensure that eligible groups of people benefit from the legal right to have a personal health budget or personal wheelchair budget.

Partners in local areas should consider all possible funding arrangements and agree this in a timely way to achieve the best outcomes for people, within the budget available. This could include:

funding arrangements in which funding is pooled across health and social care via agreement under section 75 of the NHS Act 2006. For example, funding which is part of the Better Care Fund

local authority funding following a Care Act assessment

local authority funding following an assessment under the Children Act 1989

existing NHS budget including NHS trust discharge initiatives and NHS continuing healthcare

personal budgets (which are local authority funded), personal health budgets (which are NHS funded) and integrated personal budgets and personal health budgets (which include funding from both a local authority and the NHS)

other funding initiatives such as the Rough Sleeping Initiative available to local authorities and funding available for discharge

The ICB which is to have responsibility for commissioning and paying for an individual's section 117 aftercare must always be determined in accordance with the Who Pays? rules published by NHS England. The responsible local authority is determined by reference to ' ordinary residence' rules. The different rules used for determining NHS and local authority responsibility may sometimes mean that someone who is the responsibility of one ICB is the responsibility of the neighbouring local authority, and vice versa. In 'cross-border' situations of this kind, especially where the issue arises on a regular basis, the ICB and local authority should agree local arrangements to ensure that any decisions about the joint funding of care can be made swiftly, so that there is no adverse effect on timely discharge.

Where partners in local areas agree to fund care after discharge, agreements should be in place to ensure an assessment of the person's long-term needs (if needed) at the end of this period is undertaken and no one is left without care and support if they are assessed to have long-term needs. NHS trusts and local authorities should work together to ensure that no carers are left without a carer's assessment (if needed) at the end of this period, and that adequate support is provided if they are assessed to need this beyond this period. Funding disagreements must not be the cause for delay or disruption to the care arrangements of an individual.

Local areas should also ensure clear information is available for people who may need to self-fund ongoing care, so that they can make informed choices about any ongoing care needs that do not fall within publicly funded eligibility criteria.

Considerations for particular people in hospital

Children and young people

This guidance applies to children and young people who are discharged from a mental health inpatient setting. Principles in the section 'Principles for how NHS bodies and local authorities should work together' apply to all children and young people in inpatient settings unless otherwise specified.

Longer admissions caused by unnecessary delays to discharge may have a particularly detrimental impact on children and young people's mental health, wellbeing and attachments, so early planning is vital. Children and young people, those with parental responsibility and other family and carers should be actively involved and at the centre of discharge planning and transition of care from inpatient services. An allocated member of the inpatient team should actively support transition planning in the local community, including linking up with services and organisations involved in ongoing care and support. Local authority, education partners and any other relevant community agencies involved in the child or young person's care should be involved from the start of the admission. If there isn't a named social worker already allocated on admission, the local authority should be notified to ensure that they can engage with discharge planning. The involvement of local authority and education partners should be discussed with the child and those with parental responsibility in advance of any referral being made unless there is an immediate safeguarding concern.

On admission, any looked-after children and/or any children who may be at risk of becoming a looked-after child should be identified, and the inpatient team should work closely with the local authority, including the child's social worker (if they have one through the setting's named health professional for looked-after children), to ensure the right support is in place post-discharge. There should be a clear process in place in relation to any funding decisions around post-discharge care and support, including section 117 aftercare arrangements where applicable.

For autistic children, and children and young people with a learning disability, this should be undertaken via a C(E)TR, and children and young people who are in hospital should have access to a keyworker from the ICB keyworker service. Children and young people with a learning disability and autistic children and young people may be more likely to have longer lengths of stay and be subject to greater levels of restrictive care, so discharge planning should take place early.

During the admission, all staff should be alert to any safeguarding concerns in relation to a child and young person, and follow appropriate procedures, in line with duties under the Children Act 2004 and relevant statutory guidance.

Children and young people under 18 must have continued access to education and learning throughout their hospital stay and on discharge in line with the Education Act 1996. Discharge planning should include planning for their educational needs as a central consideration. Any potential changes or disruption in their ability to access education on discharge is likely to severely impact on a successful discharge. Staff should work with the young person and those with parental responsibility to identify how best to communicate with their existing school or education setting. This should include the education setting the young person was attending prior to admission and any proposed setting for their discharge if this is different.

Where a child has an Education, Health and Care Plan ( EHCP) in place, the education team should liaise with the Special Educational Needs and Disability ( SEND) Service within the relevant local authority. It may be necessary to review the EHCP in view of the admission. Where a child does not have a EHCP in place but the education team identify that this will be required to support them in a return to education, then a referral should be made to the local authority SEND service. This referral should be shared in advance with the young person and those with parental responsibility.

For children and young people (aged 0 to 25 years) who have special educational needs and or a disability, statutory guidance on the special educational needs and disability (SEND) system for children and young people aged 0 to 25 should be considered. Consideration should be given as to how their identified needs have the right provision in place to meet their individual outcomes during admission and on discharge. This should include the provision that must be put in place in section G of their EHCP during admission. If a child or young person has a special educational need identified by school and are in receipt of SEND support but does not have an EHCP, their needs must be considered alongside their existing SEND support plan or health care plan. Working with teams across education health and social care on discharge is essential to ensure needs provision and outcomes are reviewed. There is statutory guidance for professionals supporting children and young people with special educational needs and disabilities (SEND) in residential settings.

Daily routine, structure and activities are an important part of recovery and should be central to the discharge and transition planning for young people. A suitable educational placement and section 117 after care (for those eligible) or other social care support in accordance with any assessment under the Children Act 1989, should be used effectively to support the young person to establish a daily structure and activities that supports their recovery, including the option to have greater choice and control via a personal health budget. Reasonable adjustments for children and young people who may also have a co-occurring disability should be considered at the earliest stage to ensure this is effective.

Discharge planning must involve parents, and/or those who have parental responsibility for the child or young person. For a child who is looked-after by a local authority, this must include the local authority, including the child's social worker, and should also include the child's foster carer or carers, or the appropriate person or people in the children's home where the child is placed. For a young person aged 16 to 17 who is a care leaver, their social worker should be involved, and for a care leaver aged 18 to 24, consent should be sought to involve their personal adviser if the young person has one. Discharge planning should also involve other services, as indicated by the young person's needs. This may include crisis teams, community mental health teams, substance misuse services, neurodevelopmental pathways, local authority, education - including virtual school heads for looked-after children - and voluntary services that are involved in the young persons' discharge and transition. Differing views between young people, those with parental responsibility and services should be identified early by the inpatient team and negotiated in a timely manner to ensure a safe and effective transition to the community and placement. Inpatient and community services must work together to ensure parents and other carers have the support required to provide care for the child or young person on discharge. This should include considering a range of interventions and support, such as therapeutic interventions, practical support and housing. The child or young person should be supported with the transition, depending on their individual needs and preferences. For children and young people who are transitioning to adult services, it is important that staff provide sensitive and timely support to prepare for this transition.

With consent from the young person, care plans and safety plans and personalised risk management plans should be shared with professionals and non-mental health service treatment providers that will be involved in ongoing care. Where consent is not given. Information may need to be shared in some cases, depending on individual risk factors.

People with a learning disability and autistic people

This guidance, and the principles in it, apply equally to people of all ages with a learning disability and autistic people (including children and young people) who are in a mental health inpatient setting including those specifically for autistic people and people who have a learning disability. Autistic children, young people and adults and those with a learning disability may be more likely to have significantly longer lengths of stay in hospital, have delayed discharges, and experience more restrictive care. Therefore, specific and anticipatory early planning for discharge is essential.

Building the Right Support (2015)) is a national plan that supports NHS and local authority commissioners to reduce the number of people with a learning disability and autistic people in mental health inpatient settings and to develop community services as alternatives in line with the National Service Model.

Building the Right Home (2016), complementary guidance to Building the Right Support, says that autistic people and people with a learning disability should have a choice about where they live and who they live with. Access to high quality, personalised housing, alongside care and support, is essential in enabling successful discharges of people from mental health hospitals into their own homes in the community. Embedding this element into hospital discharge processes (from as early as possible) is essential, with housing partners fully engaged from the start, especially given the considerable length of time often required to create suitable housing solutions which meet people's needs.

NHS bodies and local authorities should use the measures set out in the Building the Right Support for people with a learning disability and autistic people action plan to support good discharge for people. The action plan says that a discharge plan should be developed with the person from the start of the admission, or before, to support the person to leave hospital when they are ready. The plan should consider the purpose of admission, intended outcomes of the admission and that the person's needs after hospital are adequately planned for.

The person's family and advocates should always be involved in discharge planning, especially for children and young people, unless the person has capacity to decide that they do not want them to be involved or if there is a safeguarding or legal reason why they should not be involved.

Regular reviews of the person's care including C(E)TRs should take place during the person's stay in hospital in line with the Dynamic Support Register and Care (Education) and Treatment Review policy. Alongside this, there should be oversight visits from the commissioner responsible for paying for their care and support in line with NHS England's framework for Commissioner Oversight Visits. Host Commissioner arrangements should also be in place.

The NHS Long Term Plan includes a commitment that, by March 2024, autistic children and young people and children and young people with a learning disability either in a mental health hospital or at risk of admission to hospital will have a designated keyworker. Keyworker services help children, young people and families to get the right personalised support at the right time. They help to make sure that local systems are responsive to meeting the young people's needs in a joined-up way to avoid admission to hospital or ensure robust support for discharge and positive outcomes for the person (see more information on keyworking).

People with a learning disability and autistic people, including people who do not qualify for statutory advocacy, should have access to an advocate to support them to think about and articulate their wishes and participate in decisions about their discharge. The advocate should have expertise in working with people with a learning disability and autistic people.

It is good practice to support the person to make links with a local self-advocacy group, if they want, as this can help to build friendships and connections. Self-advocacy groups can often help with life planning and with talking to the person about how they want to live their life in the future for example:

choices about where to live and who with

how to look after money

how the person wants to spend their time

Sometimes a family member takes on the role of an advocate for the person to advocate with or for them, and where a person lacks capacity to make decisions, a family member may be best placed to support them. The person may still benefit from independent advocacy, even if they have a family member as an advocate.

'Life planning' is an increasingly used tool which can help people with a learning disability and autistic people to be at the centre of decisions about their lives. Usually this is where an independent, experienced facilitator will spend time with the person to help them think about and articulate their choices for the future. Peer-led or other advocacy often supports the process.

A personalised care and support plan ( PCSP) should be prepared, following a 'what matters to me' conversation including consideration of housing and sensory needs, that can transfer with the person into the community and is available to support discharge. The person may have been admitted with an existing PCSP, which should be reviewed and amended with the person to reflect any relevant changes.

It is important that staff support the person to prepare well for discharge. This could include individualised support that helps the person to develop skills that will help with the transition. Leave from hospital and supporting and developing connections in the community is likely to form a part of this. There should be a transition plan which all relevant agencies have signed up to. For each person it should be clear where they are on the 12-Point Discharge Plan, as outlined in the Care (Education) and Treatment Review and Dynamic Support Register policy.

So that people do not spend avoidable time in hospital when they are clinically ready for discharge, robust discharge processes should be put in place that help identify what the blockers to discharge are and to get the right people in the room to resolve them - this includes holding multi-agency discharge events (MADEs) - which are equally applicable to people with a learning disability and autistic people. Contingency planning is particularly important and necessary for people where there are complex discharge arrangements.

In line with the Accessible Information Standard, people with a learning disability and some autistic people may benefit from accessible materials to help them to participate meaningfully in decisions related to their discharge from hospital. An organisation called 'Change' have developed an accessible toolkit for this purpose. Reasonable adjustments to care as required by the Equality Act 2010 should be made at all stages of the discharge process in a personalised way.

Strong links should be made with relevant community services prior to, and during the person's stay in hospital. This should include needs related to health, social care, education, housing and any other individual needs. This is critical because some people with a learning disability and some autistic people will need support in the community after they have been discharged from hospital. This could include:

the development of highly personalised accommodation

a package of care and support from a health or care provider

ongoing support from a community mental health or community learning disability team or an enhanced Intensive Support Teams or Forensic Support Team. For guidance about these services see the Transforming Care service model specification

Putting these elements in place will require careful planning and sufficient time to arrange. It is important that planning starts early in the person's stay in hospital. Commissioners must make sure there is enough time and suitable arrangements for the person to get to know any new care team that will be supporting them outside of the hospital setting. Wherever possible an in-reach function to the inpatient setting should be provided by the community support provider, as applicable, to support transition. In addition, it may be helpful if the hospital team can provide ongoing advice and support to the community team for a defined period following discharge. These steps will help to reduce the likelihood that the person will need to be re-admitted to hospital after their discharge.

Commissioners should consider the specific needs of people with a learning disability and autistic people so that there is the right support and care available in the community. This includes access to supported and specialist housing and making sure there is the right range of specialist care and support including providers that are able to support people with high support and care needs. This also includes access to community services that are able to provide ongoing and sometimes intensive support, including crisis support, to people following discharge from hospital. For guidance on commissioning these services for people with a learning disability and autistic people, see Supporting people with a learning disability and autistic people to live happier, healthier, longer lives: bitesize guide for local systems.

It is important that people with a learning disability and autistic people do not stay longer in hospital than is needed for their care and treatment to be completed. People with a learning disability and autistic people should receive regular C(E)TRs during their stay in hospital (as well as reviews in the community) in line with NHS England's guidance on C(E)TRs Dynamic support register and Care (Education) and Treatment Review policy and guide. C(E)TRs are formal reviews, chaired by the commissioner of the person's care and with an independent clinical advisor and Expert by Experience that review the quality of care that people receive in hospital by making recommendations for their safety, care and treatment, and to help overcome barriers to the person's discharge. Where people have had a C(E)TR before going into hospital, the recommendations should be reviewed and considered throughout the person's stay. In line with NHS England guidance, people with a learning disability and autistic people in a mental health hospital should be added (with consent) to a local Dynamic Support Register so that health and care agencies can work together to plan the actions that will reduce the risk of a person's admission or re-admission to hospital.

Discharge for people with a learning disability and autistic people is helped by supporting people to keep connection with their everyday lives and having services as close to home as possible to support those connections. People should be supported to keep in touch with their families. Children and young people must be supported to continue with their education while in hospital. Discharge plans should set out how these connections will be supported and developed. This is particularly important when a person is in hospital at some distance from home. Commissioners should consider what additional measures might need to be put in place to support the person to stay in touch with family, friends and their home area.

Providers and commissioning organisations should have effective ways to gather feedback from people and their families both about their experiences in hospital and about their experience of discharge. People should be able to easily raise concerns and make complaints including using Ask Listen Do approaches.

A person with dementia

This guidance applies to people with dementia who are discharged from mental health, learning disability or autism inpatient settings. This includes people admitted to specialist dementia inpatient services or a person with dementia (who may have a dual diagnosis of a mental health condition or learning disability) admitted to other mental health or learning disability inpatient services. All of the key principles in the section 'Principles for how NHS bodies and local authorities should work together' apply to people who are suspected of having or have received a diagnosis of dementia.

Discharge planning should be tailored to the communication needs of the person with dementia, to support them to be involved in the process. For example, the inpatient team should ensure that accessible dementia-friendly information is available, which may include care plans, discharge plans and other relevant care information.

A person with a diagnosis of dementia may need specialist support on discharge from hospital. It is therefore important that discharge planning starts as soon as possible in the process, in line with the principles in the section 'Principles for how NHS bodies and local authorities should work together'. This means that post-discharge support can be arranged as soon as possible, for example referrals to the local authority for a Care Act assessment if required, or specialist support from a community mental health team specialising in dementia. Inpatient teams should share relevant information with professionals involved in onward care, including information in relation to medication, mobility needs, communication needs, swallowing issues, nutritional needs, information about future appointments and any other mental health, cognitive or physical health assessments that have taken place during the inpatient stay.

Inpatient teams may want to consider developing a life story, and/or behavioural and psychological support plans, in collaboration with the person with dementia and their carer, and they should ensure that this is shared with relevant professionals that will be involved in onward care in order to facilitate more person-centred care. Advance Care Plans should be shared with relevant professionals.

The person with dementia should be supported to prepare for discharge and the inpatient team should work closely with any unpaid or paid carers. For people being discharged to a care home, the inpatient team should consider whether it would benefit the person to visit the care home beforehand, accompanied by a staff member or carer or carers who know their needs and history. It may be more appropriate for some people with severe physical or cognitive symptoms to receive information about the proposed place of discharge through visual aids, discussion and so on. The time and day of discharge should be taken into account. For example, some people with advanced dementia may find it disorientating and distressing to be discharged in the evening due to a lack of daylight and lack of ability to coordinate with family. If the person is being discharged home, any housing and environmental needs should be considered, for example any adaptations needed, or assistive technology that needs to be installed.

If there are changes to discharge arrangements, for example a change in the person's discharge destination, the person must be involved in this decision (and a LPA attorney or deputy if they have been appointed) and recorded in the person's notes.

People admitted to mental health forensic inpatient units

This guidance applies to NHS mental health forensic inpatient settings including low secure, medium secure and high secure inpatient care. Children under 18 may be placed in a low or medium secure forensic hospitals, and adults may be placed in low, medium or high secure hospitals. All of the principles set out in the section 'Principles for how NHS bodies and local authorities should work together' apply for adults and children being discharged from secure settings, as far as they can reasonably be applied.

Everyone admitted to secure units will be detained or transferred under the Mental Health Act 1983. Some adults and children may be restricted patients and therefore subject to special controls by the Justice Secretary (see Mentally disordered offenders: The Restricted Patient System 2017 for restricted patients). Restricted patients include those adults and children transferred from the secure and detained estates under section 47 or 48 of the MHA, with restriction under section 49, those subject to a section 45A (also referred to as a hybrid order) or those who were diverted direct from court and detained under section 37 of the Act with restrictions under section 41.

Restricted patients that have transferred from the secure and detained estates may return to custody through a process of remission or could be discharged into the community from hospital, depending on the circumstances of the case. Regular and early liaison with the Mental Health Casework Section ( MHCS) who are delegated to act on behalf of the Justice Secretary, will be an essential part of discharge planning for all restricted patients.

For individuals detained under immigration powers who are transferred under section 48 of the Mental Health Act 1981, the Home Office must be involved in discharge planning. Section 53 of the Mental Health Act 1983 sets out the process by which the Secretary of State (for Justice) may, by warrant, approve remission for immigration-detained individuals transferred under section 48. The decision as to whether the individual will be remitted to an immigration removal centre ( IRC) or be released into the community on immigration bail will be taken by the Home Office.

Liaison with the prison service and IRC estate will also be necessary in some cases. In addition, it is likely that other professionals will need to be involved in the future management of this cohort of cases, including through multi agency public protection arrangements, more commonly known as MAPPAs. For those under 18, there may need to be liaison with a secure children's home or young offender's institute, as well as community forensic child and adolescent mental health services.

Other adults and children may be admitted to hospital under section 37 (a hospital order) without restrictions under section 41, section 38 (interim hospital order) or under civil sections such as section 3 of the Mental Health Act 1983. For these people, liaison with the Ministry of Justice or the secure and detained estate will not be a part of the discharge planning process, although there are specific considerations that may apply for adults and children on civil sections in secure settings. For example, even though significant risk concerns may equally apply to people placed in non-forensic inpatient units, people in a forensic setting may be more likely to have a significant risk history. A multi-disciplinary approach to risk assessment and management is therefore important. This should form part of discharge planning conversations including those involved in onward care. People subject to section 37 may also be subject to MAPPAs which should be a key consideration in regard to discharge planning.

All people in secure services should be fully involved in the discharge process and their wishes and choices should be respected and explored, even if in some cases the discharge destination may go against their wishes (for example, remission to secure and detained estates or to a particular approved address may need to happen in some cases which may not be in line with the adult or child's wishes).

For adults and children in secure settings, family and carer involvement throughout the discharge process, with the adult or child's consent, and involvement of independent mental health advocates, plays an important role in effective discharge planning. Victims will also need to be considered for both restricted and unrestricted cases because of the potential effects of any post discharge victim related conditions.

Section 117 of the Mental Health Act requires commissioners and local authorities to provide or arrange for the provision of aftercare to adults of children detained in hospital for treatment under section 3, 37, 45A, or transferred under section 47 or 48 of the Act who then leave hospital. As many adults and children admitted to secure settings will be eligible, it is particularly important that section 117 discharge meetings take place ahead of the discharge date.

The care and treatment pathway for most restricted patients will include gradual access to the community as part of their rehabilitation, and this may form an important part of the transition towards discharge. However, decisions regarding section 17 leave can only be made with the consent of the Justice Secretary, delegated to the Mental Health Casework Section ( MHCS). Requests for community leave are considered on application from the Responsible Clinician. See the guidance Request leave for restricted patients. Both the Mental Health Tribunal and the Justice Secretary, have the power to discharge a restricted patient either conditionally or absolutely. For individuals who are immigration detained and transferred under section 48 of the Mental Health Act 1983, the Home Office must be involved in decisions in relation to section 17 leave.

Discharge is usually subject to conditions (conditional discharge) and there must be appropriate supervisory and risk management plans in place. In the community a Social Supervisor and Community Responsible Clinician must be appointed, in advance, to supervise the person and submit quarterly statutory reports to the MHCS. Restricted patients may be recalled to hospital if they are considered to be posing a risk to themselves, or others, or require further mental health treatment. They can also agree to an informal admission. In such cases the MHCS should be kept updated. For individuals detained under immigration powers the Home Office must also be kept informed.

Although people admitted to secure wards may be more likely to experience longer inpatient stays, this should not always be assumed, and it is important that discharge planning starts at the point of admission as set out in the section 'Principles for how NHS bodies and local authorities should work together', due to the likelihood of need for specialist support following discharge. This means that there is adequate time for the appropriate support to be arranged, which could include:

specialist supported accommodation

funded care package following a Care Act assessment

support from a specialist forensic community health team and/or liaison with secure and detained estates

Commissioners of health and social care should consider the needs of adults and children being discharged from secure settings in the commissioning of local services, so that appropriate accommodation and support is available locally, dependant on need.

People experiencing, or at risk of, homelessness

A person is homeless if they do not have accommodation that they have a legal right to occupy, which is accessible and physically available to them (and their household) and which it would be reasonable for them to continue to live in. Homelessness does not just refer to people who are sleeping rough; it also includes those living in insecure or inadequate housing.

People who are homeless or at risk of homelessness, including rough sleeping, should be identified on admission to hospital. Hospitals have a duty to refer people who they think might be homeless, or at risk of becoming homeless within 56 days of admission. With the person's consent, the person should be referred by the inpatient team to the relevant local authority homelessness or housing options teams as early as possible during their stay, under the requirements of the Homelessness Reduction Act 2017. Commissioners of health, social care and housing services should consider the needs of people experiencing homelessness being discharged from mental health hospitals, including the commissioning of appropriate accommodation and support upon discharge. This might include specialist intermediate care and step-down services while longer-term care is being planned, specialist supported accommodation, and/or wraparound or 'settle-in' care in the community following discharge.

NICE guidance on integrated health and social care for people experiencing homelessness (2022) sets out core principles on how to approach care and support for people experiencing homelessness, including rough sleeping. The guidelines focus on delivering integrated, person-centred, empathetic, trauma-informed care in psychologically informed environments. Delivery of care is recommended through specialist homelessness multi-disciplinary teams, and through homelessness leads in mainstream services working together to understand and meet the needs of people experiencing homelessness. Effective support to access and engage with services should recognise and respond to people's previous traumatic experiences and use evidence-based approaches including outreach.

People with co-occurring mental health and drug and alcohol conditions

Where inpatients have co-occurring mental health and drug or alcohol conditions, the local drug and alcohol treatment provider should be involved in or consulted on their treatment and care as well as involved in post-discharge care plans where appropriate. It is important that pharmacological treatment of drug/alcohol use disorders is effectively implemented during the inpatient stay, including opiate substitution therapy or drug/alcohol managed withdrawal. Mental health services should refer to Drug misuse and dependence: UK guidelines on clinical management (2017) for guidance on delivering such treatment and actively engage with the community drug/alcohol treatment service for relevant patient treatment information. There should be an 'everyone's job' and 'no wrong door' approach taken by both mental health and drug and alcohol treatment services for people with a co-occurring need, including policies and pathways in place in line with Better care for people with co-occurring mental health and alcohol/drug use conditions, (2017).

The NICE National Guideline 58 on co-existing severe mental illness and substance misuse (2016) recommends that (upon discharge from inpatient settings) mental health services in the community lead the care for these people, with support as needed for specific drug/alcohol treatment interventions, for example opiate substitution therapy. For children and young people with a co-occurring mental health and drug/alcohol conditions, they would normally be cared for by a community mental health team for children and young people and a local authority children's social care team where appropriate. Where specialist services are in place in the local area, there should be joint work with local children and young people's drug/alcohol providers.

Where the patient is a child and there are concerns about co-occurring mental health and drug/alcohol conditions, consideration should be given to a referral to the local authority Children's Social Care team for an assessment under the Children Act 1989. This should be discussed in advance with those with parental responsibility in most cases, unless there are safeguarding concerns and/or the child is considered to have competence and has objected to them being informed. There may be associated risks that the child has been exploited and any concerns in this regard should also be referred to the local authority. Appropriate services should be planned as part of the discharge process.

A person with no recourse to public funds

People receiving compulsory treatment under a court order, or who are liable to be detained in an NHS-funded hospital or deprived of their liberty in a hospital (for example, under the Mental Health Act 1983 or the Mental Capacity Act 2005) are exempt from charge for all treatment provided, in accordance with the court order, or for the duration of their detention. See guidance on NHS Cost Recovery-overseas visitors which includes information on exemptions.

Section 117 aftercare services should be provided irrespective of the person's immigration status, including someone who may be subject to the no recourse to public funds condition. People are eligible for aftercare services if they were admitted to hospital under the following provisions of the Mental Health Act 1983:

section 3 (detained in hospital for treatment)

a hospital order made under section 37 or 45A (ordered to go to hospital by a court)

section 47 or 48 (transferred from prison or immigration detention to hospital for treatment)

The legal right to a personal health budget under section 117 also applies. If a person with no recourse to public funds is being discharged from hospital and is homeless but does not require accommodation for the purpose of reducing the risk of hospital readmission, then social services must undertake a needs assessment to establish whether accommodation can be provided under the Care Act 2014. If an adult has been detained or transferred under the Mental Health Act 1983, accommodation may be available to them as part of their section 117 Mental Health Act aftercare package. Social services support is not classed as a public fund and so people with no recourse to public funds are eligible to access support from social services.

For individuals on immigration bail, the Home Office must also be involved in any arrangements made for provision of section 117 aftercare support under the Mental Health Act 1983. Any immigration bail conditions the individual may be subject to, including the restriction on a place of residence, must be considered when arranging section 117 support. Any other support provided to the individual, such as asylum or schedule 10 support, must also be factored in when arranging section 117 support.

Where the patient is a child and lives with a family without recourse to public funds, a referral should be made to the local authority Children's Social Care service for an assessment under the Children Act 1989. This would not apply to an Unaccompanied Asylum-Seeking child, who will be looked-after by their local authority.

Roles and responsibilities in the discharge process

This section sets out the responsibilities for NHS organisations and local authorities in the discharge process. This includes commissioners of services, NHS trusts and local authorities.

Commissioners of health and social care services

These commissioners should:

ensure there is clear agreement around which of them is to be responsible for paying for the person's care or, if the NHS body and the local authority are to share the costs, the proportion in which they will do so. This should include responsibility for paying for any additional care that may need to be put into place, for example if the person is in crisis or at risk of re-admission to hospital. This includes the use of pooled funding arrangements, Continuing Health Care arrangements and section 117 aftercare. See Annex B for national guidance on how budgets and responsibilities should be shared to pay for section 117 aftercare (Mental Health Act 1983). Commissioners should also ensure eligible people have access to a personal budget

work in partnership to plan and commission sufficient provision to meet the needs of the population, commissioning specialised mental health, learning disability and autism services, including for children and young people and for those with multiple and complex needs. This must include working with the relevant NHS-Led mental health learning disability and autism Provider Collaboratives

work in partnership to co-ordinate local financial flows for post-discharge care and support, including monitoring all local spend and co-ordinating local funding arrangements

ensure local systems have an identified executive lead to provide strategic oversight of mental health discharges, ensuring that appropriate procedures - including escalation processes - are in place and being followed and that there are no avoidable delays to discharge

NHS trusts providing mental health inpatient services

For more information around responsibilities in acute inpatient services for adults, see guidance on Acute inpatient mental health care for adults and older adults.

Hospital clinical and managerial leadership teams

These teams should:

ensure that people and their chosen carers (including those with parental responsibility for children and young people) are the centre of discharge planning and are actively involved throughout the process, with appropriate input from relevant professionals and services involved in their ongoing care

work with individuals and their chosen carers to inform care plans and discharge planning, including undertaking risk assessments. Other relevant professionals should be involved, and joint assessments should take place where appropriate, for example with other members of the inpatient multi-disciplinary team, community mental health team or local authority adult/children's social care team

arrange dedicated staff to support and facilitate hospital discharge. This should include making arrangements to ensure there is transport for people to return home from hospital, making links with the relevant team to ensure that they have put in place arrangements for follow-up within 72 hours of discharge (this may be sooner, depending on clinical risk) from a crisis or community-based mental health team, and ensuring people have full information about the next steps of their care and receive an individualised care and support plan detailing post-discharge support

ensure that required medication and essential equipment are provided at the point of discharge, and that information about this is provided to onward care providers, the individual and, where appropriate, their family and chosen carer or carers

identify people at risk of delayed discharge and ensure this is escalated according to local protocols, so an assessment can take place if required

identify carer or carers, including young carers and other children within the family unit, who may be in need of information and/or support on admission, and make sure this is recorded on electronic records

identify any looked-after children or any children who may be at risk of becoming a looked-after child, and work closely with the local authority in discharge planning

identify people experiencing or at risk of homelessness on admission, and with the person's consent, make a referral to the relevant local authority as early as possible during their stay

maintain timely and high-quality transfer of information (including discharge plans and care and treatment plans where appropriate) to primary care and/or community mental health teams (CMHTs), crisis resolution and home treatment teams (CRHTTs), and all other relevant health and care professionals

maintain provision for senior clinical staff to be available to support ward and discharge staff with appropriate risk-management and clinical advice arrangements

engage with commissioning bodies and regional colleagues to support clinical and medical leaders in implementing discharge processes

closely monitor hospital discharge performance data to ensure discharge arrangements are operating effectively and safely across the system

Local authorities

All local authorities should:

take the lead on local care market shaping, including contracting responsibilities, as outlined in the Care Act, and ensure the right support is in place for looked-after children and those at risk of becoming a looked-after child upon discharge in line with duties under Children Act 1989 (see Statutory guidance on securing sufficient accommodation and access to services for looked-after children)

work with CQC and other regulators to ensure safeguarding and quality of care, advising NHS colleagues where action is needed to ensure safe discharge arrangements are in place

engage local housing authority services to provide housing and homelessness support and advice for people requiring housing assistance or individuals experiencing or at risk of homelessness on discharge from hospital

agree a single lead local authority point of contact arrangement so that each NHS trust and foundation trust has a single point to approach when co-ordinating the discharge of all people, including mental health discharges

work with partners to co-ordinate activity with local and national voluntary sector organisations to provide services to people requiring support around discharge from hospital and subsequent recovery

carry out an assessment upon the request or appearance of the needs of unpaid carers, and this assessment must consider whether the caring duties are appropriate or excessive. This is also applicable to young carers and parent carers. For young carers, this assessment must consider whether it is appropriate or excessive for the young carer to provide care

ensure that children have continued access to education while in hospital (under the Education Act 1996)

Local authority adult social care teams

These teams should:

make provision for Care Act assessments of need, financial assessments and longer-term care planning to take place following discharge. They should pay for services to meet assessed need

ensure social work professionals can contribute to hospital based multi-disciplinary discussions and decision making occurring before discharge

continue to conduct safeguarding activities throughout the discharge process where necessary

provide capacity to review care provision and change if necessary in line with the person's wishes, good practice and legal responsibilities

assess whether an unpaid carer has support needs (or is likely to do so in the future) and, if the carer does, what those needs are (or are likely to be in the future). For adult unpaid carers, a statutory carers assessment must be offered under the Care Act 2014

work with NHS bodies to ensure appropriate data collection and ensure its use supports the best outcomes for individuals and the local population

work with children's social care teams to ensure a whole-family approach is being adopted where a child is caring for an adult

Local authority children's social care teams

These teams should:

ensure children's social workers and other relevant professionals can contribute to hospital based multi-disciplinary discussions and decision making occurring before discharge. For autistic children and those with a learning disability, this should include engaging with community C(E)TRs and inpatient C(E)TRs

undertake assessments of the needs of children and young people in line with duties under the Children Act 1989 to ensure appropriate accommodation and support is in place post-discharge. This includes ensuring support is in place for looked-after children or children and young people who are at risk of becoming looked-after children

raise any safeguarding concerns regarding any child or young person they come into contact with, in line with statutory duties

provide capacity to review care provision and amend this to reflect the child or young person's circumstances where necessary, at an appropriate point in line with good practice and legal responsibilities

Local authority housing teams

These teams should:

work in partnership to help ensure people's housing needs are assessed and that they can be discharged into suitable accommodation on discharge. This includes cases where adaptations are required to a person's home

in partnership with the local authority with social care responsibility, carry out an assessment to provide adaptations for eligible older and disabled people, in line with statutory duties under the Care Act 2014

local authority housing benefit teams should work closely with health and social care commissioners to advise on the rent element of any future identified housing arrangements. This is due to their responsibilities for administering Housing Benefit and determining whether accommodation meets the criteria for 'specified' accommodation (including 'exempt' accommodation) - and therefore whether Housing Benefit can be paid to cover housing costs

fast track adaptations to help facilitate hospital discharge where appropriate. This includes for people with a mental health condition, who are autistic, have a learning disability or cognitive impairment, like dementia

provide support for a person who is homeless under the requirements of the Homelessness Reduction Act 2017

support people to keep their homes when they go into hospital, for example with accessing housing benefit. In addition to local authority housing teams, it is also important that housing providers are fully engaged in discharge planning arrangements - whether to help plan people's future housing arrangements, or to support them (as their landlord) to maintain their current home (their tenancy), if possible

Further information on existing legal duties on health and social care bodies

Many people admitted to a mental health inpatient unit are admitted on a voluntary basis. Other people may be detained or transferred under the Mental Health Act 1983 involuntarily if they are assessed to meet criteria under the MHA. There is statutory guidance Code of Practice: Mental Health Act 1983 which outlines how functions under the Act should be carried out. This includes the 5 principles that underpin this:

least restrictive option and maximising independence

empowerment and involvement

respect and dignity

purpose and effectiveness

efficiency and equity

The Code of Practice also sets out how people should be informed of their rights under the Mental Health Act 1983, including their right to an Independent Mental Health Advocate and how relatives and carers should be involved. The guidance also sets out people's right to leave from the hospital ('section 17 leave'), with authorisation from a doctor or clinician. In case of restricted patients, agreement of the Secretary of State for Justice may be required before leave can be agreed.

Section 117 of the Mental Health Act requires commissioners and local authorities, in co-operation with voluntary agencies, to provide or arrange for the provision of aftercare to people detained in or transferred to hospital for treatment under sections 3, 37, 45A, 47 or 48 of the Act. This includes people granted leave of absence under section 17 and people going on CTOs or who are conditionally discharged. It applies to people of all ages, including children and young people. This can be used to pay for health, social care, supported accommodation and other services to maintain a person's mental wellbeing. Guidance on how budgets and responsibilities should be shared to pay for section 117 aftercare is included in Annex B. Similarly, Ofsted is responsible under the Care Standards Act 2000 (CSA 2000) for regulating establishments and agencies that provide children's social care services. ICBs and other relevant bodies have a duty to ensure that eligible groups of people benefit from the legal right to have a personal health budget or personal wheelchair budget. For more information see guidance on the legal rights to have personal health budgets and personal wheelchair budgets.

The Care Act 2014 sets out a single route to establishing an entitlement to care and support for adults with eligible needs for care and support, and the entitlement to support for unpaid carers. The Act is also clear about the steps that local authorities must follow to work out this entitlement, and to help people understand the process. This includes a duty to assess and meet people's eligible care needs in relevant circumstances and to conduct a financial assessment where necessary.

Section 2 of the 2014 Act and section 3 of the 2014 Act require local authorities to take steps to prevent, reduce or delay needs for care and support for local people, with a view to ensuring integration of care and support services with health provision, including the provision of housing. Section 2 requires local authorities to have regard to identifying unpaid carers with needs for support that are not being met.

The Health and Care Act 2022 revoked Schedule 3 to the Care Act 2014, which required long-term health and care needs assessments to take place before discharge from hospital. The Health and Care Act 2022 also provides the Secretary of State for Health and Social Care the power to issue guidance on the duty to cooperate (as between NHS bodies and local authorities) by way of an amendment to section 72 of the NHS Act 2006 and amends section 74 of the Care Act 2014 to introduce a new duty on relevant NHS trusts to involve people and unpaid carers early in discharge planning where it is appropriate to do so.

NHS bodies and local authorities should take into account any existing duties under the Children Act 1989, Children Act 2004 and the Children and Families Act 2014.

Children Act 1989 places a general duty on local authorities to promote and safeguard the welfare of children in need in their area by providing a range of services appropriate to those children's needs. Section 31 of the Act sets out the circumstances under which a court may make an order placing a child in the care of the local authority (a care order). The Act also sets out the functions of local authorities in relation to looked-after children, including a duty under section 22(3) to safeguard and promote the welfare of children in their care.

Children Act 2004 places a duty on local authorities in England to make arrangements to promote co-operation with key partners and local agencies, with a view to improving the well-being of children in the authority's area. The Act also places a duty on a range of agencies, including local authorities, the police and health services, to ensure that they consider the need to safeguard and promote the welfare of children when carrying out their functions. The statutory guidance, 'Working Together to Safeguard Children', sets out how individuals and organisations should work together to safeguard and promote the welfare of children and young people in accordance with the relevant legislation

Part 3 of the Children and Families Act 2014 includes provisions to support the physical, mental health and emotional wellbeing of children and young people with special educational needs or disabilities, including the requirement for Education, Health and Social Care services to work together to meet the needs of children and young people with SEND. Part 5 sets out the support that must be provided for young carers and parent carers. According to the Act, young carers should be offered the appropriate support that avoids excessive or inappropriate caring. For both parent carers and young carers, local authorities must carry out an assessment upon the request or appearance of need.

NHS England and ICBs must comply with their duties in relation to NHS continuing healthcare ( CHC) and NHS-Funded Nursing Care ( FNC), as set out in the National Health Service Commissioning Board and Clinical Commissioning Groups (Responsibilities and Standing Rules) Regulations 2012, while having regard to the National Framework for NHS continuing healthcare and NHS-funded Nursing Care.

The Care Quality Commission ( CQC) monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety. The fundamental standards set in law provide a clear baseline below which care must not fall, and the CQC will be able to take enforcement action against providers that do not meet these standards. Health and social care providers must meet the requirements set out in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Regulation 9 states that the care and treatment of people using services must be appropriate, meet their needs and reflect their preferences. Regulation 12 states that care and treatment must be provided in a safe way. To comply with this regulation, care providers must, among other things, assess the risk to people's health and safety of receiving any care or treatment.

Care Quality Commission (CQC) guidance for providers on meeting the 2014 Regulations states that providers must carry out, collaboratively with the relevant person, an assessment of the needs and preferences of the person needing care and support. Assessments should be reviewed regularly and whenever needed throughout the person's care and treatment. This includes when they transfer between services, use respite care or are re-admitted or discharged. Reviews should make sure that people's goals or plans are being met and are still relevant, as specified in Regulation 9: Person-centred care - Care Quality Commission.

The Health and Care Act 2022 inserted a new section 46B to the Health and Social Care Act 2008 which sets out new powers for the CQC to assess ICSs as well as to assess how local authorities deliver their Care Act duties. CQC will be assessing ICSs against their core purpose, to tackle inequalities, including health inequalities and improve outcomes for people, as well as against the themes of leadership, integration and quality and safety set out in the Health and Care Act 2022. In this context, ICS is defined as the ICB, its partner local authorities and registered service providers in the ICB area. For local authorities, CQC will be assessing aspects of commissioning and market shaping, in particular how the care and support needs of people and communities are understood and whether there is a varied and resilient provider market with sufficient capacity to meet demand now and in future. CQC will also assess how local authorities work towards integrating care and support services with those provided by partner agencies to achieve better outcomes for people who need care and support and to reduce inequalities.

NHS bodies also have a duty to refer a person who is homeless, or may be threatened with homelessness, to local authority homelessness and housing options teams under the requirements of the Homelessness Reduction Act 2017.

Escalating concerns about care

Local health and social care systems should have effective mechanisms for people to raise concerns about care and support that are clearly communicated to people using services, their families, their carers and advocates, and service providers. These should clearly set out who is responsible for what and at which step of the process they should be engaged.

Concerns should be escalated via the locally agreed escalation mechanism, overseen by the identified ICB Discharge Executive Lead. Local areas will have flexibility over how this is implemented locally, but they should ensure mechanisms are agreed with all partners, and that there is a clearly identified responsible person at each stage of the discharge process. Escalation mechanisms should be co-designed with people, including carers, who have experience of escalating issues in the past to ensure they work. How to escalate concerns should be included in the discharge information.

Where a complaint needs to be raised against an NHS body, it should be made to them directly in the first instance. This can be done through the relevant body's complaints department, or its Patient Advice and Liaison Service ( PALS). PALS can also provide information about the NHS complaints procedure, including how to get independent help if needed. Where a complaint needs to be made by an individual or provider this should be raised directly with the NHS body providing the service in the first instance. A complaint can also be raised with the commissioner of the service. Where this does not yield satisfactory results, the complaint can be raised through the Parliamentary and Health Service Ombudsman.

Where a complaint needs to be raised against a local authority or care provider, it should be made to them in the first instance. If this does not yield satisfactory results, or the complaint is not answered within a reasonable time, a complaint can be raised through the Local Government and Social Care Ombudsman.

Individuals can also provide information to local Healthwatch organisations and the CQC, which may carry out a range of actions including inspecting the relevant body if it has the powers to do so. While CQC is not able to take forward individual complaints, all the information it receives about the quality of care that people experience is invaluable to its understanding about quality and risk and where it should be focusing its regulatory efforts.

Implementation of this guidance

NHS bodies and local authorities in England have a statutory duty to have regard to this guidance.

Many organisations were consulted during the development of this guidance, including NHS trusts, ICBs, local authorities, voluntary sector organisations as well as people with personal experience and their chosen carers. We will continue to engage with key stakeholders to understand the impact of this guidance and make updates where necessary.

Annex A: further information on mental capacity considerations

According to the Mental Capacity Act ( MCA) 2005, which applies to people aged 16 and over, mental capacity is decision and time specific, and assessments should not be an indication of an individual's ability to make decisions generally. If there is a reason to doubt that a person has the capacity to make relevant decisions about their discharge arrangements at the time the decisions need to be made, a capacity assessment should be carried out as part of the discharge planning process. Mental capacity to make a certain decision where appropriate should be reviewed regularly as this can change. MCA principles should be taken into account:

a person aged 16 or above should be assumed to have capacity in relation to a particular decision in relation to discharge, unless it is established that they lack capacity

mental capacity is decision and time specific, and an assessment that a person lacks the relevant capacity about a particular decision should not be made about a person's ability to make decisions generally

assumptions should not be made about a person's capacity based solely on their mental health condition, whether they have a learning disability or autism, their drug or alcohol use or a dementia diagnosis or anything else

a lack of capacity should not be assumed due to a person being detained or transferred under the Mental Health Act 1983 or due to previous mental capacity assessments relating to other decisions

in line with the third principle of the MCA, a person should not be treated as unable to make a decision merely because they make an 'unwise' decision

in line with the second principle of the Mental Capacity Act, a person should not be treated as unable to make decisions unless all practicable steps have been taken to support them to do so without success. If the person is assessed to lack the mental capacity to make a relevant decision about discharge, a 'best interests' decision must be made in line with section 4 of the Mental Capacity Act. More information on mental capacity considerations is provided in section 3

The Mental Capacity Act 2005 applies to people aged 16 or over. However if a child who is below the age of 16 is considered ' Gillick competent', they may be able to make decisions around their discharge planning. Staff should therefore consider whether a child is 'Gillick competent' in relation to relevant decisions around discharge. For children who are not considered 'Gillick competent' or for young people aged 16 or 17 who lack capacity to make decisions in relation to discharge, someone with parental responsibility should consent to decisions on their behalf where practitioners are satisfied that it is appropriate to rely on parental consent. For 16- and 17-year-olds, a best interests decision may be needed under the MCA.

In certain circumstances during discharge planning, health and care providers might determine that someone is, or will be, 'deprived of their liberty', as a result of the proposed arrangements for their care and treatment. In these circumstances, decision makers must comply with the legal requirements regarding the person's right to liberty (Article 5 of the European Convention on Human Rights (ECHR)). For adults residing or who will be residing in a care home or hospital, this would usually be provided by the Deprivation of Liberty Safeguards (DoLS). This includes a requirement to carry out a capacity assessment before a decision about discharge to a care home is made, if there is proper reason to consider the person lacks the capacity to decide whether or not to be accommodated at the care home for the purpose of being given the relevant care or treatment, and the arrangements may amount to a deprivation of liberty. For children under 18 this may be through a section 20 (shared care order) or section 47 (full care order) of the Children Act (1989).

Any decision by the decision maker must be taken specifically for each person and not for groups of people. The starting point should always be to consider whether the restrictions can be minimised or removed, so that the person will not be deprived of their liberty.

Introduction

This guidance has been issued following the recommendation of the Independent Review of the Mental Health Act 1983 that there should be guidance 'on how budgets and responsibilities should be shared to pay for section 117 aftercare'. This guidance is for England only and applicable across all ages to include section 117 responsibilities for children and young people ( CYP) and adults.

There are a range of different care and support arrangements outside of inpatient settings with access and entitlements covered by a variety of legal frameworks, funding streams and responsible bodies. Aftercare under section 117 applies to a specific group of people who have been discharged from an inpatient episode following a compulsory period of treatment for their mental disorder and who need aftercare services to reduce the risk of re-admission.

Section 117 is an enforceable freestanding duty placed on both local social services authorities and NHS commissioners to provide non-chargeable aftercare services to eligible people as defined in the MHA legislation. While decision-making responsibility for funding will typically sit with senior commissioning managers in both NHS and local authority organisations, it is also important to recognise that the care planning, review and application for section 117 funding resource is often undertaken by health and social care practitioners.

This document provides guidance to clarify:

the application of the Mental Health Act (MHA) and the Code of Practice guiding principles to the shared responsibility of managing budgets and responsibilities under section 117 aftercare

the need for greater consistency and transparency to the shared decision making and joint arrangements operated by local authority social services (LSSAs) and NHS commissioners in regard to shared section 117 budget planning and management

that people who are entitled to section 117 aftercare are expected to be central to decision making about their own aftercare

that personalised care and support planning will ensure that what matters to the person and their family, carers, networks is intrinsic to any aftercare plans which are agreed

The care and support statutory guidance places a duty on local authorities to commission or provide mental health aftercare for the area in which the person concerned was ordinarily resident immediately before they were detained or transferred under the 1983 Act, even if the person becomes ordinarily resident in another area after leaving hospital.

Note that the ICB which is responsible for commissioning and paying for the NHS element of an individual's section 117 aftercare must always be determined in accordance with the 'Who Pays?' rules published by NHS England. Who Pays? contains a detailed section (paragraph 18) dealing with determining NHS responsibility for detention and aftercare under the Mental Health Act.

In the White Paper, Health and social care integration: joining up care for people, places and populations, great emphasis is placed on the essential role of leaders for bringing partners together to deliver outcomes that really matter to people and populations. The joint section 117 duty provides a good opportunity for integrated working where local leaders are responsible for delivering the right outcomes and value for money, tackling health disparities, and for how well they have brought together the relevant partners to do so.

Great effort and persistence is required by local leaders to ensure that organisational financial arrangements and system complexity do not cause obstacles in the delivery of section 117 aftercare to people in need of services. Success is dependent on trusted relationships between partners, open channels of communication, and defining outcomes that matter with the recipients of aftercare arrangements. The section 117 financial arrangements should not be a barrier to the development of fully integrated, flexible and responsive aftercare planning.

Section 117 aftercare

Aftercare services are defined within the Mental Health Act 1983 as those "meeting a need arising from or related to the person's mental disorder" and "reducing the risk of a deterioration of the person's mental condition (and, accordingly, reducing the risk of the person requiring admission to a hospital again for treatment for mental disorder)". Section 117 applies to people who have been detained or transferred under sections 3, 37, 45A, 47 or 48 and have been discharged from hospital and who then cease to be detained or transferred under the Mental Health Act 1983. This includes people with a learning disability and autistic people.

Section 47 National Health Service and Community Care Act 1990 provides the legal framework for local authorities to carry out an assessment of aftercare needs and considering whether those needs call for the provision of services. This is a distinct legal duty from that laid out in section 9 of the Care Act 2014, which must be carried out by a local authority if an adult appears to have needs for care and support.

Current guidance states that integrated commissioning boards ( ICBs) and local authorities should interpret the definition of aftercare services broadly. As such, aftercare services could include:

health care

social care

employment services

supported accommodation

services to meet the person's wider social, cultural and spiritual needs (previously case law suggested that helping a previous inpatient with problems of family relationships could be an aftercare service, however the meeting of social, cultural and spiritual needs is much broader)

services that support a person in regaining or enhancing their skills, or learning new skills, in order to cope with life outside the hospital

Key principles for people subject to aftercare

The implementation of this guidance should be informed by the 5 overarching principles laid out within the MHA Code of Practice emphasising each person as an individual within the context of their family needing hope, agency and opportunity to aid their recovery. These are:

the least restrictive option and maximising independence

empowerment and involvement

respect and dignity

purpose and effectiveness

efficiency and equity

Least restrictive option and maximising independence

Aftercare services are arranged for people to receive care and support once they leave hospital. Section 117 does not provide legal authority, by itself, to restrict or deprive the liberty of a person. Additional legal authority is necessary.

Empowerment and involvement

People should be enabled to exercise choice and control when developing a personalised care and support plan that details their aftercare arrangements. Services should prepare and support individuals to co-produce personalised care plans taking account of their need to sometimes take positive risks and build opportunities for independent living. Access to section 117 information should be promoted across a variety of communication formats (for example 'easy read') and people should be supported to understand their entitlement to section 117 aftercare while they remain subject to the Act.

Respect and dignity

Aftercare 'needs' should initially be identified under section 47 of the National Health Service and Community Care Act 1990 and support must be provided and commissioned in a manner that:

respects and acknowledges the person's qualities, strengths, abilities, knowledge and past experience

in particular, respects and acknowledges a person's individual diversity including any protected characteristics under the Equality Act 2010

Aftercare planning and review should be framed within the context of supporting an individual's recovery and promoting their strengths. People receiving section 117 aftercare should not be institutionalised within this legal definition. Rather, people should be supported, enabled, and empowered using a strengths-based approach to move to independence and discharge from section 117 wherever possible

Purpose and effectiveness

Local authorities and NHS commissioners should co-ordinate local funding arrangements which are designed to support people with achieving the outcomes laid out within their section 117 discharge plans and to minimise the likelihood of someone experiencing a relapse in their mental health, which may lead to the necessity for re-admission. Aftercare plans should be focused on supporting people to cope with life outside of the hospital setting with the opportunity for review. In the event that a person is in receipt of a funded package of care, assurance should be in place to ensure that provision remains relevant, proportionate and cost effective.

Efficiency and equity

Funding decisions must be conducted in a timely manner prioritising and promoting the least restrictive approach while promoting the strengths of the individual. No assessment, care or support arrangements should be refused or delayed because of uncertainty or ambiguity as to which public authority is responsible for funding an individual's health and/or care provision.

Organisational assurance

All local social service authorities and NHS commissioning organisations must share a responsibility for making section 117 funding decisions for people entitled to aftercare within a robust quality assurance framework. This should demonstrate effective transparency and accountability when delivering this joint duty and avoid the risk of duplication, delayed transitions, inefficiency and poor experience of the person in receipt of care and support.

The Mental Health Act Code of Practice (2015) at paragraph 33.7 states that local authorities and ICBs (relevant health bodies) should maintain a record of people for whom they provide or commission aftercare for, and what aftercare services are provided. Both local social service authorities and NHS commissioners, working alongside NHS provider organisations should maintain joint section 117 single records of people (including children and young people) who are entitled to section 117 aftercare, making reference to funding decisions and relevant supporting information. This should ensure information remains up to date and under regular review offering a reliable chronology in relation to organisational responsibilities. Joint single records should conform to up-to-date multi-agency information, sharing agreements and data protection legislation. Funding arrangements, processes and supporting information should be clearly detailed within individual records for the purposes of sharing with people in receipt of section 117 services and to professionals who are required to apply them.

NHS and local authority partners should agree a lead officer in each respective organisation to share management and maintenance responsibilities of the joint single section 117 records which should be monitored and updated on a regular basis for the purpose of accuracy and assurance.

The process underpinning section 117 joint funding and decision making should be clearly and transparently laid out in locally agreed policies that are jointly agreed across both NHS and local authority partners. This will include the need to ensure that:

a personalised approach is actively supported

funding application details are simple to follow

robust and timely decision-making processes are in place

monitoring and review arrangements are clear and audited to ensure they are happening

roles and responsibilities of partners and dispute management protocols are easy to follow, transparent and timely

funding decisions are recorded accurately with accompanying detailed narrative providing evidence to illustrate the historical chronology of care provision resourced under the section 117 duty

Information about section 117 arrangements should be available to service users in accessible language and communications with reference to how it might be available to people. People who become eligible for section 117 should be automatically informed and provided with detail of their entitlement to non-chargeable aftercare and reminded of this on review. See the appendix for available information from MIND and Rethink.

Workforce development planning should include multi-agency health and social care training and development for all staff involved with the implementation of section 117 arrangements in local areas. Particular reference should be made to ensuring that staff understand what they need to consider when making a funding application alongside the care assessment and planning process.

The section 117 maturity matrix is available (see the appendix) for NHS bodies and local authorities to self-assess their local system section 117 arrangements with a view to improve and provide assurance to ICPs from a quality and financial perspective in compliance with the legislation.

In the event of a person being detained under a section of the MHA which would cause an effect on their eligibility for aftercare it is considered best practice for the host local authority Approved Mental Health Professional Service to notify the area within which the person resides in order for local services to consider their legal responsibilities.

East of England case study: a collaborative approach to improving section 117 aftercare across the East of England

In September 2021, the Regional Mental Health Programme Team from NHS England (East) developed a regional forum for section 117 in collaboration with all 3 integrated care systems ( ICSs) from the region. This was prompted by concerns raised by systems relating to local resourcing of section 117 aftercare and difficulty in identifying impacts of packages of care.

Through discussion with all ICSs, there was agreement to undertake a benchmarking exercise to review the costs, activity and processes for delivering section 117 aftercare in 2021 to 2022. The purpose behind this was to understand approaches being taken, any gaps in knowledge and support future work to improve consistency and quality of section 117 aftercare in supporting individual's recovery journeys - thereby reducing unwarranted variation.

The benchmarking was generally agreed as a beneficial exercise and helped in surfacing challenges faced by systems which included:

an opportunity for reflection of where section 117 'ownership' sits within ICSs

the challenges of maintaining a central picture in ICSs with multiple local authority footprints

variable provision of personal health budgets and these not always universally understood

The benchmarking exercise also reviewed current processes being followed to support new packages of care as well as discharge from section 117 aftercare. All ICSs shared learning from taking part in the exercise, the main themes of which were:

uncovering areas of practice that could be improved and challenges to overcome

supporting local dialogue aimed at improving joined up work for section 117 aftercare

acknowledging that identifying detailed information for section 117 aftercare was challenging, including bringing a central picture together

organisations working together and keeping the individual at the heart of any decisions made

the importance of working closely between health and social care on activities such as joint funding panels

acceptance of joint responsibility for section 117 aftercare

maintaining 'registers' shared between agencies to ensure correct info shared

joint reviews to avoid lack of communication

the need for joint NHS and local authority working to develop alternative models of care/support/housing to move away from reliance on residential care

Moving forward into 2022 to 2024, this work will continue including a potential refresh of the benchmarking based on 2022 to 2023 activity. Through establishing this group in the East, key areas are emerging where we can work together collectively in terms of processes, outcomes and impact of section 117 aftercare for those receiving packages of care.

Jointly agreed processes regarding funding arrangements

In circumstances where someone appears to be in need of aftercare they must be assessed under section 47 of the National Health Service and Community Care Act 1990. Section 117 funding arrangements and associated funding decisions should be based upon clear and transparent funding arrangements which can be evidenced by each partner organisation. Success is based upon clarity of access to section 117 funding arrangements by people using services and staff, transparent decision-making processes and reporting mechanisms of both NHS and social care organisations.

Section 117 funding arrangements should therefore be determined in accordance with local agreement between NHS and LSSAs to meet the needs of the eligible persons. Local systems will choose to administer a joint funding process which will fall within different broad categories of aligned or pooled budget arrangements.

The duty to fund aftercare under the MHA should be approached as an opportunity to explore stronger integrated arrangements between NHS and local authorities. As described within the government white paper, Health and social care integration: joining up care for people, places and populations:

There is no 'one-size-fits-all approach', given the variation between systems in terms of the populations they serve and the existing organisations they contain, but areas should consider the mechanisms available for them to deliver integrated section 117 after care arrangements, for example through section 75 NHS Act 2006.

We want to ensure there is flexibility to enable as much collaboration and integration as possible and the government is currently reviewing the legislation underpinning section 75 NHS Act 2006 to see if we should update it to enable further use. Pooling agreements will remain subject to both NHS and local authority leadership within both systems and places agreeing what constitutes a fair and appropriate contribution.

Surrey case study

Surrey County Council and NHS Partners have been working to develop their section 117 partnership arrangements across a large and complex geographical footprint involving different commissioning decision makers and one NHS Mental Health Provider Trust. Following a typically traditional approach to aligned funding until 2017, local authority and NHS Partners agreed to take a shared approach to section 117 funding decisions with 50/50 splits on all new funding agreements. This approach is still not described as a pooled budget although this arrangement has been sustained with the intention to improve and strengthen in the forthcoming months. The factors which describe the success of this approach include:

a system-wide, senior commitment to leadership and management of the joint section 117 aftercare duty, including the creation of a section 117 partnership board and a section 117 joint operational group

no reported disputes

no reported delayed discharges due to funding decisions

division of lead commissioning responsibilities with NHS responsible for MH hospital placements and nursing homes and local authorities responsible for home-based care, supported living and residential care

These positive joint working arrangements are effective. However, challenges remain and are being addressed in regard to maintenance of a joint section 117 register, information governance and data compliance across different recording systems, demonstrating assurance on the quality and frequency of section 117 review activity, increasing numbers of people being subject to section 117 entitlement and the associated increase in care costs for those in need of funded arrangements. Continuous improvement aims to address the various financial and quality issues relating to section 117 funding and practice with the development of a specialist team to deal specifically with this critical area of business. Whole-system section 117 staff training is well established and more effective business reporting is planned to demonstrate quality, safety and efficiency to our residents and partners.

Review of aftercare

It is essential to ensure that the needs of all people in receipt of a funded section 117 care plan are kept under regular review at agreed intervals. This guidance provides the expectation that NHS and local authorities should conduct a joint review of the section 117 care plan no later than every 12 months, which must take into account the views of the person who is receiving the aftercare. The timetable of review arrangements should be refreshed and updated in the event of potential change in circumstances for example a hospital admission and discharge plan.

The review of aftercare should include an opportunity for the person to reflect on what is working well, and what changes might need to take place. It is an opportunity to check the relevance of the care plan, and that it maintains a 'strengths based' approach and is up to date. The review is also an opportunity to ensure that all crisis and contingency plans remain accessible and realistic for the person concerned and their carers.

It is also an opportunity to address whether circumstances indicate that section 117 status needs to continue or whether it should be ended in line with guidance set out within chapter 33 of the MHA Code of Practice, paragraphs 33.20 to 33.24.

Transition for young people to adult services

In the event that someone becomes eligible for section 117 aftercare while in receipt of services as a child or younger person, it is essential that preparations for transition to adulthood are made. This is critical where funding decisions might be involved. This will require the attention of relevant health and social care commissioning managers working together between NHS and local authority organisations and across CYP and adult services, who will need to ensure that the young person remains at the centre of all care planning arrangements and associated communications. The child's parent and/or carer should also be involved as appropriate.

Specific reference to the application of funding for young people subject to section 117 needs to be made in local section 117 policies and procedures, referencing the role of the various agencies that might be involved with the experience of transition. It is incumbent on CYP commissioning managers to bring people entitled to section 117 to the attention of adult commissioning colleagues in a timely manner to support effective future planning, and it is incumbent on adult commissioning colleagues to request details of those young people subject to section 117 who may require adult services from their CYP counterparts.

Local CYP and adult commissioners from NHS bodies and local authorities should convene on a regular basis to review the circumstances of young people who are subject to section 117 and ensure that suitable preparations are being made to support a structured and smooth transition allowing for the forecasting of care costs and necessary market provision.

The shared maintenance of accurate record keeping should reflect the chronology of section 117 decision making and communication between NHS and local authority partners. This is critical to ensure continuity for the young person with the commissioned care arrangements in anticipation for the handover of funding responsibility to adult commissioners from the age of 18 years.

As a standalone duty, section 117 remains the responsibility of both NHS bodies and local authority commissioners regardless of the funding stream. While this remains the case, it is essential that all commissioning stakeholders work with the young person and their family alongside other relevant stakeholders to promote a strengths-based approach to assessment, care planning and review.

Conditionally discharged patients

Conditionally discharged patients are eligible for aftercare under section 117 and should be subject to shared funding decision-making arrangements between the NHS and local authorities.

Relevant aftercare bodies share a responsibility to make preparations for aftercare particularly where conditional discharge is in view.

As stated within the MHA Reference Guide (2015) 'Responsible aftercare bodies must consider making preparations in any case where they have good reason to think that there is a real possibility that the person will be discharged, and where appropriate aftercare can be arranged. In particular, they must use their best endeavours to put in place aftercare which would allow a person to be conditionally discharged in accordance with a provisional decision of the Tribunal (a 'deferred conditional discharge').

The maintenance of accurate chronologies within case records is important for all persons subject to aftercare. This remains the case for people who are subject to s37/41 MHA to ensure that decisions relating to their ordinary residence are based on reliable information and minimise the risks of disputes between health and social care funding bodies.

People subject to community treatment orders (CTO)

NHS bodies and local authorities will need to determine how to effectively share section 117 funding arrangements for people subject to a CTO at local level. This will be dependent on locally agreed shared section 117 mechanisms such as pooled or aligned budgets as described above.

Different factors might be considered if operating an aligned budget when taking section 117 funding decisions into consideration for people subject to a CTO including:

the longevity of the proposed order over a longer-term under s17a being applicable to a jointly funded arrangement

not using CTOs as an opportunity to pass on a financial pressure from one organisation to another

the use of a CTO to support a person's recovery following an acute episode of poor mental health with the prospect of an increased level of social care support in the event of their subsequent recovery

People subject to 'leave of absence' arrangements

The section 117 duty includes people granted leave of absence under section 17 and people going on community treatment orders ( CTOs). It applies to people of all ages, including children and young people.'

An important Court of Appeal case in December 2018 provides relevant commentary on the relationship between section 117 aftercare and section 17 leave. The case of R (CXF) v Central Bedfordshire Council [2017] confirms that section 117 aftercare is likely to apply in certain cases to section 17 leave when a person is living in the community on leave of absence - either full-time or for part of the week. However, section 117 did not apply in cases such as this, whereby CXF was granted regular leave of absence under section 17 of the MHA for purposes of escorted day trips into the community.

Dispute management

Disputes are known to occur about section 117 funding responsibilities between responsible bodies including NHS Organisations and local authorities. Section 117 disputes between NHS Organisations and local authorities should be addressed locally in the first instance. There may be a role for the integrated care partnership ( ICP) to facilitate a dialogue with key partners to seek agreement and to ensure alignment with the integrated care strategy.

Where disputes do take place between ICBs, there is existing guidance which should mitigate the risk of disruption to the person subject to section 117 provision.

In the event of uncertainty as to the 'responsible commissioner' within the NHS, clarification should be sought by referring to Who Pays? guidance.

In the event of a dispute between 2 or more NHS bodies or ICBs regarding the Responsible Commissioner, there is provision within Appendix 1 of 'Who Pays?' to seek guidance from NHS England regional teams or the national team.

Disagreements about payment responsibility between NHS commissioners must not:

delay a person's necessary assessment, care or treatment

result in the person or family, or a local authority, having to pay for care or treatment which should have been funded by the NHS

mean that a provider which is properly providing clinically appropriate services to a person remains unpaid

Section 4d of Appendix 1 of 'Who Pays?' makes it clear that the relevant ICBs must conclude an interim, without prejudice agreement, so as to facilitate timely discharge and meet the requirements in the 3 bullet points above.

Disputes between local authorities can be referred to the Secretary of State for a determination under s40 of the Care Act and the Care and Support (Disputes Between Local Authorities) Regulations 2014.

Local authorities must take all reasonable steps to resolve the dispute between themselves. They must also not allow the existence of the dispute to prevent, delay, interrupt or otherwise adversely affect the meeting of the needs of the adult or carer to whom the dispute relates to.

In the event that no local authority is willing to accept ordinary residence responsibility for an individual, then the local authority where the individual is physically present must take interim responsibility, until the dispute is resolved.

Discharging someone from section 117 aftercare

Eligibility for section 117 aftercare services is defined within the Care Act as described above. The MHA Code of Practice (paragraph 33.20) states that the most clear-cut circumstance in which aftercare would end is when the person's mental health has improved to a point where they no longer need services to meet needs arising from or related to their mental disorder.

The involvement of the person and their carer where applicable is essential in the decision-making process for the successful ending of aftercare.

NHS continuing healthcare and section 117 aftercare

The relationship between section 117 aftercare and NHS continuing healthcare ( CHC) is set out in the National Framework for NHS continuing healthcare and NHS funded Nursing Care National Framework for NHS CHC.

It is not necessary to assess eligibility for CHC if all the services in question are in fact to be provided as section 117 aftercare services.

However, if a person in receipt of section 117 aftercare services has ongoing needs that do not arise from, or are not related to, their mental disorder and thus may fall outside of the scope of section 117, or the person develops additional needs (for example following a stroke), this may trigger a need to consider their eligibility for CHC in relation to these separate needs.

CHC must not be used to meet section 117 aftercare needs.

Where an individual in receipt of section 117 aftercare develops physical care needs resulting in a rapidly deteriorating condition which may be entering a terminal phase, consideration should be given to the use of the Fast-track pathway tool.

The National Framework is very clear that local policies should be in place to deal with the approach to section 117 aftercare and that it is preferable to manage section 117 budgets and NHS continuing healthcare budgets separately where they are distinct entitlements.

Personal budgets and personal health budgets, including direct payments

Personal budget ( PB): the budget is wholly funded by the local authority through a direct payment, an individual service fund (ISF), third party budget or a notional budget.

Personal health budget ( PHB): the budget is wholly funded by the NHS through a direct payment, a third-party budget (similar to a social care ISF) or a notional budget.

Integrated personal budget: the budget includes funding from both the local authority and/or education and the NHS through a direct payment, an ISF, third party budget or national budget.

Personal budgets ( PBs) including those funded by health ( PHBs) use social care or health funding (or a combination of both) to create an individually agreed personalised care and support plan that offers people of all ages greater choice and flexibility over how their assessed health and wellbeing needs are met. There are good examples of personal budgets being offered to support people to access mental health support in mental health services.

People receiving section 117 aftercare have a right to have a personal budget and/or personal health budget.

PBs and PHBs for section 117 aftercare should not be applied restrictively or prescriptively. Examples show PBs and PHBs being used to meet identified health and well-being outcomes, as specified in the personalised care and support plan, in flexible and creative ways. These include supporting access to activities that promote self-management, community engagement and support recovery.

A direct payment cannot be used to pay for any NHS charges, such as prescription or dental charges.

Prisoners and immigration detained individuals

Any uncertainty or dispute regarding Responsible Commissioner or Ordinary Residence should be resolved as set out above.

It is important to remember when drawing up section 117 aftercare plans for prisoners or immigration offenders that some individuals may require a proposed care provider to be approved by the probation service and Home Office regarding its suitability. Good practice indicates the involvement of the probation service and Home Office at the section 117 aftercare planning meeting.

Any immigration bail conditions the individual may be subject to, including the restriction on a place of residence, must be considered when arranging section 117 support. Any other support provided to the individual, such as asylum or schedule 10 support, must also be factored in when arranging section 117 support.

Care and support and aftercare (choice of accommodation)

Where a local authority is providing or arranging accommodation under section 117 of a type specified in the Care and Support and Aftercare (choice of accommodation) Regulations 2014 and a person expresses a preference for particular accommodation, then the local authority must provide or arrange for that accommodation under section 117A, provided that conditions prescribed in those regulations are met. Types of accommodation could include care home, shared lives or supported living arrangements. If the preferred accommodation costs more than the amount the local authority would expect to be the usual cost of accommodation of that kind, then that additional cost needs to be met by the person receiving the care or another person. Any immigration bail conditions the individual may be subject to, including the restriction on a place of residence, must be considered when arranging section 117 support.

Section 117 and immigration status

Section 117 aftercare services are available regardless of a person's immigration status or their nationality. Immigration exclusions under schedule 3 of the Nationality, Immigration and Asylum Act 2002 do not apply. When preparing to discharge someone who has no recourse to public funds from section 117, consideration must be given to the person's immigration status and entitlement to support in the UK. The need for provision to meet common care and support needs not related to a mental disorder must be assessed separately under the Care Act, Children Act and Human Rights Act 1998.

Useful resources

This information from Rethink explains if you can get free aftercare under section 117 of the Mental Health Act 1983.

Section 117 aftercare - Mind explains the rights you have to get your section lifted if you are being detained in hospital under the Mental Health Act, and your rights to care and support after leaving hospital.

The latest Who Pays? NHS England Guidance on Determining which NHS commissioner is responsible for commissioning healthcare services and making payments to providers.
Code of practice: Mental Health Act 1983 - see chapter 33 No Recourse to Public Funds - A toolkit for social workers in England Local Government Ombudsman - section 117 Aftercare - Guidance for Practitioners
Appendix: section 117 maturity matrix

This quality assurance tool is designed to assist local systems in self-assessing their current compliance with the national guidance on section 117 aftercare.

It is designed to enable local systems to identify areas that might need further operational, strategic, commissioning and financial development, and agree actions to initiate improvement for people subject to this legal entitlement. This could be RAG (red, amber, green) rated, if helpful.

Section 117 record

Underdeveloped

We do not have reliable information about the number of people eligible for section 117 who we have responsibility for.

We do not have any plans in place to be able to report on this.

Developing

We have some understanding of the number of people eligible for section 117 who we have responsibility for.

We have plans in place to be able to report on this.

Mature

We have a section 117 single joint record with responsible officers allocated in the NHS and local authority delegated to provide assurance

We have a section 117 register on our system.

Section 117 training and professional support

Underdeveloped

We do not have section 117 training in place for our clinicians and practitioners across the local system.

Clinicians and practitioners find it difficult to receive timely professional and legal advice regarding section 117 matters.

Mechanisms do not exist in the local system to share local (case based or other) learning regarding section 117.

Operational staff are unclear about how to make section 117 funding applications.

Developing

We have some section 117 training in place for our clinicians and practitioners across the local system. This is provided as and when required.

Clinicians and practitioners are sometimes able to receive timely professional and legal advice regarding section 117 matters.

There are limited opportunities in the local system to share local (case based or other) learning regarding section 117.

Some staff are unclear about how to make section 117 funding applications although know where to seek advice and guidance.

Mature

We provide ongoing section 117 training for our clinicians and practitioners across the local system. It is accessible to NHS and local authority staff. This training includes updates and refreshers and is easily accessible.

Clinicians and practitioners are able to receive timely professional and legal advice regarding section 117 matters.

There are established mechanisms in the local system that enable (case based or other) local learning regarding section 117.

All staff are clear about how to make a section 117 funding application and what is expected of them within set timeframes.

Inpatient discharge planning for section 117 eligible people

Underdeveloped

Clinicians and practitioners are not clear about their responsibilities regarding section 117 aftercare.

People are not provided with information regarding their section 117 eligibility and entitlement to section 117 aftercare.

Few people being discharged from inpatient units have a section 117 aftercare plan to accompany their discharge.

Developing

Some clinicians and practitioners are clear about their responsibilities regarding section 117 aftercare.

Some people are provided with information regarding their section 117 eligibility and entitlement to section 117 aftercare.

Some people being discharged from inpatient units have a section 117 aftercare plan to accompany their discharge.

Mature

Clinicians and practitioners understand their responsibilities regarding section 117 aftercare.

People are proactively provided with information regarding their section 117 eligibility and entitlement to section 117 aftercare.

All people being discharged from inpatient units have a section 117 aftercare plan to accompany their discharge.

Section 117 readmission rates

Underdeveloped

We are unable to report on the numbers of people receiving section 117 aftercare who are readmitted to inpatient mental health provision.

We are unable to use section 117 readmission data to inform operational and strategic learning across the system.

Developing

We are able to identify some people receiving section 117 aftercare who are readmitted to inpatient mental health provision.

We are able to use some data to inform operational and strategic learning across the system

Mature

We are able to report on the numbers of people receiving section 117 aftercare who are readmitted to inpatient mental health provision.

We use this data to inform operational and strategic learning across the system.

Section 117 reviews

Underdeveloped

Some people in our population have a regular section 117 review, in accordance with the MHA Code of Practice.

Few section 117 reviews are undertaken jointly between health and social care practitioners

Developing

Most people in our population have a regular section 117 review, in accordance with the MHA Code of Practice.

Some section 117 reviews are undertaken jointly between health and social care practitioners.

Mature

All people in our population have a regular section 117 review within each 12-month period and in accordance with the MHA Code of Practice.

Section 117 reviews are undertaken jointly between health and social care practitioners as appropriate.

Discharge from section 117

Underdeveloped

We do not have a joint policy and process that enables people to be discharged from section 117 aftercare.

We do not have joint template forms that support the process of being discharged from section 117 aftercare.

We do not discharge people from section 117 aftercare.

Developing

We are developing a jointly agreed policy and process that enables people to be discharged from section 117 aftercare.

We are developing joint template forms that support the process of being discharged from section 117 aftercare.

We discharge some people from section 117 aftercare.

Mature

We have a joint policy and process that enables people to be discharged from section 117 aftercare.

We have joint template forms that support the process of being discharged from section 117 aftercare.

We discharge people from section 117 aftercare when appropriate and people are fully involved and engaged in such decisions.

Section 117 partnership

Underdeveloped

We do not have a jointly agreed section 117 policy in place.

We do not have a joint funding arrangement in place.

We do not have section 117 partnership meetings that consider section 117 operational issues.

We do not have section 117 partnership meetings that consider section 117 strategic issues.

People in our population often have their discharge from hospital delayed due to issues regarding section 117 aftercare.

We do not share data and finance activity regarding section 117 between NHS and local authority partners.

Developing

We are developing a jointly agreed section 117 policy.

We are developing a joint funding arrangement.

We have some section 117 partnership meetings that consider section 117 operational issues.

We have some section 117 partnership meetings that consider section 117 strategic issues.

Some people in our population have their discharge from hospital delayed due to issues regarding section 117 aftercare.

We share some data and finance activity regarding section 117 between NHS and local authority partners.

Mature

We have a jointly agreed section 117 policy in place which is subject to an agreed schedule of review.

We have a joint funding arrangement in place.

We have regular section 117 partnership meetings that consider section 117 operational issues.

We have regular section 117 partnership meetings that consider section 117 strategic issues.

No one in our population has their discharge from hospital delayed due to issues regarding section 117 aftercare.

We regularly share data and finance activity regarding section 117 between NHS and local authority partners

Patient experience

Underdeveloped

People tell us that they do not feel engaged and empowered in drawing up their section 117 aftercare plan.

People tell us that none of the people that they had identified as important in drawing up their section 117 aftercare plan were involved in it.

Developing

People tell us that they do not always feel engaged and empowered in drawing up their section 117 aftercare plan.

People tell us that not all of the people that they had identified as important in drawing up their section 117 aftercare plan were involved in it.

Mature

People tell us that they feel engaged and empowered in drawing up their section 117 aftercare plan.

People tell us that they had all the people that they wanted involved in drawing up their section 117 aftercare plan.

Commissioning and provision of section 117 aftercare

Underdeveloped

It is often unclear which organisation or individual is responsible for commissioning section 117 aftercare arrangements.

There are regular delays in inpatient discharge due to appropriate care not being available.

We do not have any plans to engage with providers to develop the care market to meet this need.

There are regular delays in inpatient discharge due to appropriate housing not being available.

We do not have any plans with housing authorities to meet this need.

Care providers (home based care, supported living, residential and nursing care, day services and so on) in our area do not understand the importance of their role in supporting people's section 117 aftercare and contributing to the success of the section 117 aftercare plan.

Developing

It is sometimes unclear which organisation or individual is responsible for commissioning section 117 aftercare arrangements.

There are sometimes delays in inpatient discharge due to appropriate care not being available.

We have plans to engage with providers to develop the care market to meet this need.

There are sometimes delays in inpatient discharge due to appropriate housing not being available.

We are developing plans with housing authorities to meet this need.

Care providers (home based care, supported living, residential and nursing care, day services and so on) in our area have some understanding of the importance of their role in supporting people's section 117 aftercare and contributing to the success of the section 117 aftercare plan.

Mature

It is clear which organisation or individual is responsible for commissioning section 117 aftercare arrangements.

There are rarely delays in inpatient discharge due to appropriate care not being available.

We have existing mechanisms to engage with providers to develop the care market to meet any unmet need.

There are rarely delays in inpatient discharge due to appropriate housing not being available.

We have existing arrangements in place with housing authorities to meet this need.

Care providers (home based care, supported living, residential and nursing care, day services and so on) in our area understand the importance of their role in supporting people's section 117 aftercare and contributing to the success of the section 117 aftercare plan.

Section 117 children and young people (CYP) and transition to adulthood

Underdeveloped

We are not able to identify people under 18 who have section 117 eligibility.

There is little understanding in our local system as to how to apply section 117 in our work with CYP.

There are no local section 117 policies and processes in place across the local system to inform and underpin our work with CYP.

We do not yet have appropriate support and services for CYP who are eligible for section 117.

For CYP reaching adulthood, we do not have effective arrangements in place to ensure that:

their section 117 aftercare continues when the individual reaches 18

there is a positive transition experience where case transfers are timely, effective and provide the best outcomes for the individual

Developing

We can identify some CYP who are eligible for section 117.

There is some understanding about our responsibilities to CYP who are eligible for section 117.

There are some section 117 policies and processes in place (or being developed) across the local system to inform and underpin our work with CYP.

We have some appropriate support and services to CYP who are eligible for section 117.

For CYP reaching adulthood, we have some arrangements in place to ensure that:

their section 117 aftercare continues when the individual reaches 18

there is a positive transition experience where case transfers are timely, effective and provide the best outcomes for the individual

Mature

We are able to identify all CYP who have section 117 eligibility.

There is clarity about our responsibilities to CYP regarding section 117 aftercare.

There are local section 117 policies and processes in place across the local system to inform and underpin our work with CYP.

We are able to provide appropriate support and services to CYP who are eligible for section 117.

For CYP reaching adulthood, we have effective arrangements in place to ensure that:

their section 117 aftercare continues when the individual reaches 18

there is a positive transition experience where case transfers are timely, effective and provide the best outcomes for the individual

Personal health budgets (PHBs) for section 117 aftercare

Underdeveloped

It is difficult within our system to have section 117 aftercare PHBs.

Developing

We are creating the architecture and budget so that we are able to award section 117 aftercare PHBs.

Mature

We have an established process in place to award and monitor section 117 aftercare PHBs.

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Discharge from mental health inpatient settings

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It is vital that organisations across the health system work together to ensure effective discharge planning and the best outcomes for people who are discharged from hospital, and that people and their chosen carers are fully involved in the process.

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NHS Culture of Care national standards        (values/ ethics/ empowerment/ autonomy/ relational)       

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NHS Culture of Care national standards        (values/ ethics/ empowerment/ autonomy/ relational)       

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Introduction

In 2022, the Mental Health, Learning Disability and Autism Inpatient Quality Transformation Programme was established to support cultural change and a new bold, reimagined model of care for the future across all NHS-funded mental health, learning disability and autism inpatient settings.

The culture of care standards for mental health inpatient care set out in this guidance support all providers to realise the culture of care within inpatient settings everyone wants to experience - people who need this care and their families, and the staff who provide this care. They apply across the life course to all NHS-funded mental health inpatient service types, including those for people with a learning disability and autistic people, as well as specialised mental health inpatient services such as mother and baby units, secure services, and children and young people's mental health inpatient services.

The standards represent the collective vision we all hold for our inpatient services. They were co-produced with people with lived experience of inpatient services and their families; nurses, psychiatrists, psychologists, allied health professionals and other staff who work in inpatient settings at various levels of the organisation; voluntary sector organisations; royal colleges; and academic experts. Further consultation was undertaken with key stakeholders across the system, at national, regional, system and provider level, and with additional focus groups of people with lived experience, particularly those with experience of secure inpatient settings and people from Black and minority ethnic communities.

We acknowledge that the standards are ambitious, particularly in the context of current workforce pressures. However, we know that achieving a positive workplace culture is critical to improved patient outcomes [ 1]. It tackles barriers we know get in the way of staff providing the care they want to give to patients by boosting employee engagement and performance [ 2] and staff retention [ 3]. The culture of care articulated in this guidance will support patients and their families to flourish, and staff to flourish; to be proud to work in inpatient care and supported to deliver the care they came into their profession to give.

The standards reflect the potential for change across all service types, and convey the core belief that each person has the power to make a difference. Collectively, and with the right implementation support, that power can mobilise whole organisations and communities.

Note on language

This guidance has been written with everyone who may use mental health hospitals in mind, and the language we use reflects this inclusive approach.

We have avoided buzzwords, recognising that some ideas and frameworks that are intended to initiate positive change have instead been co-opted or assimilated into mainstream culture and practice in ways that can be painful for patients and families to experience. We have precisely described the improvements needed to create meaningful changes in inpatient services.

We do refer to 'patient' where we want to clearly differentiate those receiving care from staff or people more generally and make explicit the power differentials within inpatient settings. We considered patient to be the least objectionable term, supported by literature [ 4] and general consensus within our design group, including people with lived experience. Where we refer to 'people' we intend to be inclusive of patients, staff and visitors.

We have tried to select language that respects the multiple understandings of mental distress, crisis and illness, and the range of needs and experiences that might bring people to hospital. While the guidance avoids traditional terms like 'serious mental illness', it has been co-produced with, and is relevant to, the range of people who may need hospital care, including those who identify or are sometimes described as having such illness.

Our vision for inpatient care
Our co-produced vision for inpatient care
The purpose of inpatient care is for people to be consistently able to access a choice of therapeutic support, and to be and feel safe. Inpatient care must be trauma informed, autism informed and culturally competent.

Being in hospital is a form of restriction in and of itself, and it is our moral and legislative duty to provide the least restrictive experience possible within inpatient settings with a clear focus on balancing the right to liberty with therapeutic benefit.

To support this vision we have co-developed 12 overarching core commitments, each of which has a set of associated standards. Work to improve the culture of care on inpatient wards - creating the conditions where patients and staff can flourish - should focus on these core commitments.

1. lived experience: We value lived experience, including in paid roles, at all levels - design, delivery, governance and oversight

2. safety: People on our wards feel safe and cared for

3. relationships: High-quality, rights-based care starts with trusting relationships and the understanding that connecting with people is how we help everyone feel safe

4. staff support: We support all staff so that they can be present alongside people in their distress.

5. equality: We are inclusive and value difference; we take action to promote equity in access, treatment and outcomes

6. avoiding harm: We actively seek to avoid harm and traumatisation, and acknowledge harm when it occurs

7. needs led: We respect people's own understanding of their distress

8. choice: Nothing about me without me - we support the fundamental right for patients and (as appropriate) their support network to be engaged in all aspects of their care

9. environment: Our inpatient spaces reflect the value we place on our people

10. things to do on the ward: We have a wide range of patient requested activities every day

11. therapeutic support: We offer people a range of therapy and support that gives them hope things can get better

12. transparency: We have open and honest conversations with patients and each other, and name the difficult things

An illustration summarising the 12 culture of care standards for all NHS funded mental health inpatient settings

The culture of care standards for each of these components are set out in the sections below.

In addition, the standards are aligned to 3 key approaches - trauma-informed, autism-informed and culturally competent care - to support the ambition for equality focused inpatient care.

Core commitments and standards for the culture of inpatient care

1. Lived experience

Standards

all patients are supported to have a voice in their care

all patients' experiences are systematically measured, valued and used to improve care

paid peer workforce at all levels are an integral part of the multidisciplinary team (MDT)

lived experience leadership roles are at all levels of the organisation

lived experience representative of the service type and local community is embedded in service design, quality improvement, governance and oversight

infrastructure is in place to support people with lived experience in these roles, and designed by people with lived experience

What these standards mean in practice

"Communication is key. If changes are put in place in an inpatient unit make sure to get feedback from the autistic young people who experience these changes. Take into consideration what they think works well and any concerns they may have."

Beth W, It's Not Rocket Science, p51

Lived experience of mental illness, learning disability and autism, trauma and adversity, and service use is sought, listened to, valued and acted on at every level of the organisation. Alongside paid lived experience and peer roles, the infrastructure supports a broad range of voices to be heard, and prevents lived experience becoming assimilated or co-opted. Integrating lived experience takes the form of true co-production, not just consultation or engagement. All training is co-designed and co-delivered by people with lived experience.

Within our ward environment, we demonstrate how we value people's lived experience, alongside professional or learned expertise, in everything we do. We respect individual patient's perspectives and wishes in their care, including those of patients who feel let down or disappointed in our service so far or whose voices are often not easily heard.

We have robust methods to capture patient feedback and act on it; and patient experience (quantitative and qualitative) is measured as part of our quality assurance process. We aim to co-produce measures or use existing co-produced measures of experience, such as VOICE [ 5].

We have peer roles on our ward as an integrated part of our MDT - so that everyone can engage with multiple perspectives to challenge and improve practice - and value the distinctiveness of these roles. The fidelity to peer support is protected and peer workers do not participate in restraint or other coercive practices such as the compulsory administration of medication [ 6].

"Patients and their carers should be present, powerful and involved at all levels of healthcare organisations from wards to the boards of trusts." [ 7]

We are committed to growing lived experience leadership roles across the organisation, including a patient director and patient safety partners, to ensure co-production across service design, quality improvement and oversight. Those in lived experience roles can access training and development, and have a clear career pathway, alongside opportunities to move into different roles. People with lived experience are employed at a range of bandings.

People in lived experience roles can also support staff through supervision and reflective spaces.

"Participants described a lack of understanding by decision makers and staff about the experiences of multiple disadvantage and discrimination which had contributed to their eventual admission to secure care. They mentioned that they needed someone to talk to who could empathise, acknowledge and understand their specific experiences as Black African and Caribbean men, such as a peer worker or advocate."

NHS England. Developing the 'Forensic Mental Health Community Service Model' background information resource (2 of 5): Service user perspectives.

The lived experience workforce should reflect the communities they serve, and provide culturally competent support, recognising the importance of shared cultural identity in peer work.

We pay attention to every aspect of what it means to be a peer; for example, being a mum in perinatal services.

"Just knowing that there were other mums, it was just like the biggest comfort ever. I just felt like, oh my gosh I'm not the only one." [ 8]

We recognise the emotional toll of lived experience work. All people in lived experience and peer roles, both voluntary and employed, are well supported, and reasonable adjustments are made, including part-time working and job share options. Support includes reflective practice and lived experience supervision, offered within the MDT and from a separate peer or lived experience space or structure [ 9].

2. Safety

Standards

all people (patients, staff and visitors) feel safe on the ward

we respect and protect people's civil and human rights

staff prioritise building therapeutic relationships to support patient safety

people always receive a compassionate response when they feel unsafe

the approach to safety is relational

people's mental health and physical health needs are understood and met (see also Needs led)

What these standards mean in practice

We take action to keep people (patients, staff and visitors) safe, protecting their physical, relational, emotional and cultural safety. We ensure people are safe from sexual and gender-based harm [ 10], and our facilities are safe for people at risk of harm to themselves or others. We believe people when they tell us they feel unsafe, or have experienced sexual or gender-based harm, and report incidents when they occur.

We protect and value time to build meaningful therapeutic relationships with patients as we know this, over the use of surveillance technology, keeps them safe in everything we do. One-to-one observation can be a way to spend time and be with the person, thereby building a therapeutic relationship [ 11]. Our focus is easing people's discomfort and distress, and we recognise that having someone to listen 24/7 can shift a person's perspective to one of hope for the future [ 12].

We are person centred [ 13] in our approach to safety. We ask patients and lived experience workers what makes them feel safe and what makes them feel unsafe on the ward; the former might include access to basic items such as a phone charger, hygiene products and information about the ward. We involve the person and their loved ones in safety planning. Where the person lacks the capacity to discuss what makes them feel safe, we seek information from their support network, patient record or community team, and listen to their feedback as we care for them.

"I was on 1:1 support and this often meant that there were men in my room overnight. Regular male staff were great, it's easier if you know them, but it was often people I'd never met before. I asked to go home because I didn't feel safe and it made me more stressed. They told me they didn't have enough female staff."

Emily, It's Not Rocket Science, p98

We have consistent and safe staffing levels. Our staff feel safe from harm, and are psychologically informed, supported and trained to be alongside people in extreme states of distress or dissociation. They are supported to respond to people's distress with compassion and without punitive approaches such as behavioural contracts, sanctions (criminal or otherwise) and withholding care [ 14].

"Risk assessment tools should not be used to predict future suicide or repetition of self-harm, or to determine who should or should not be offered treatment. The guideline suggests risk assessment should focus on the person's needs and how to support their immediate and long-term psychological and physical safety." [ 15]

We recognise the impact of racism, stereotyping and bias in assessment of risk and question the impact of such discrimination in decision-making about people's safety. Therapeutic collaboration is prioritised in providing safe care, and positive risk-taking approaches [ 14] are not employed against people's wishes, such as early discharge. We do not use risk assessment tools and scales to assess harm to self, and never tell people that they have capacity to take their own life. We adjust our care for differences in age and understanding, and can evidence this in practice.

Where we need to keep people safe from harming others, we recognise and prioritise the value of relational approaches to safety and security. We prioritise staff time, skill and confidence in being able to foster a relational approach to safety and security.

"Relational security is primary: women's needs are more closely attuned to and respond better to 'relational security' rather than 'physical security'. This requires staff to have a deep understanding of the women on the wards and how they respond to their environment and changes within it or planned transitions across them." [ 16]

Multiple reports and Safeguarding Adults Reviews, such as that into the care of Joanna, Jon and Ben at Cawston Park, evidenced that the physical health care needs of autistic individuals and those with a learning disability are often neglected or ignored during mental health inpatient admissions, sometimes with devastating outcomes.

Staff are equipped to support people with their physical health needs, and understand the higher risk of premature mortality and co-morbidities and the issues of diagnostic overshadowing in this group.

3. Relationships

Standards

staff take the time to get to know the people on their wards and build a trusting relationship with them

staff are competent in building relationships with different people and responding compassionately to extreme states of distress

staff understand and respond to different individuals' needs, for example with reasonable adjustments

the ward builds and maintains consistent relationships with people's chosen support network

people and families feel care is culturally competent and meets people's diverse needs

the organisation supports staff to protect and prioritise the therapeutic relationship

the organisation supports the development of healthy team dynamics that positively impact on patient care and patient experience

What these standards mean in practice

Positive relationships between staff and the people they support are fundamental to a person-centred care environment. We recognise that trusting therapeutic relationships are the strongest predictor of good clinical outcomes [ 17, 18], and staff are supported to prioritise building relationships with patients over non-essential paperwork and other tasks. Training in relational approaches to care is available for all staff.

"Time with staff and time to talk to staff was the most common response when women were asked what helped them and their recovery." [ 16]

"Empathy, respect and empowerment can be felt when an alliance is built on acceptance and trust. Without a therapeutic relationship, patients are a lot less likely to engage with and make effective use of mental health services and may be put off accessing services in the future." [ 19]

We spend time with people in distress, irrespective of how the distress presents, and actively listen to and believe what they say. We consider this time alongside people as the most valuable in supporting patients to survive and manage their mental health crisis, and maximise its therapeutic potential.

We recognise the need to work particularly hard to build relationships and make collaborative decisions with people who lack capacity, and that it can take longer to listen to people who may communicate in complicated and unusual ways. We recognise how frustrating it must be for someone not to be heard and understood when they are already distressed and in a strange environment, and we actively support alternative and/or augmented methods of communication. Staff are skilled in the communication style that works for the person; see also 4. Staff support.

We also recognise that people report good experiences of care when staff are compassionate, caring and respectful, and are engaged and supported by staff in ways that help them feel valued and understood (including their cultural identity); good experiences reduce the use of coercive measures. Staff are supported to engage authentically and strong communication and interpersonal skills are prioritised in staff recruitment, development and training. Bank and agency staff are given the time to get to know people on the ward and build relationships with them.

"Compassion requires a reflexive ethos, an environment that prioritises therapeutic relationships, and challenging of policies and cultures that normalise oppression." [ 20]

We take responsibility for the breakdown of relationships between staff members and patients, and we have co-produced procedures in place should this occur.

"... we know that the single greatest factor that supports resilience is stable and supportive adult-child relationships ... the clinician is likely to - at least initially - be a surrogate for the stability and connectedness that her clients missed as children. ...As clinicians, if we are attentive to the idea that the consistent, supportive relationship we have with our clients is itself the most critical intervention in helping clients recover from early trauma, then we are less likely to miss the important opportunities that may arise for showing that support, for offering co-regulation, and for providing stability. ... "I see you, I hear you, and I believe you" is often the most potent way we will express to a client that they are finally being understood." [ 21]

We respond promptly and compassionately to patient requests. We recognise that some patients may prefer to work with particular staff, perhaps because of a shared interest or cultural identity, and accommodate such preferences where possible. We embrace and recognise dependency as a positive aspect of trusting relationships, and we do not pathologise patient attachments to individual staff members.

Ward staff value forming good relationships with community staff and broader services within the local community, including voluntary, community and social enterprise (VCSE) organisations, peer groups, advocacy organisations, sports clubs and faith-based organisations. These relationships facilitate welcoming handovers as people approach transitioning back to the community from inpatient care. For example, rather than simply giving a person a leaflet about Mind, ward staff may offer: "let me call my colleague Sam at Mind and arrange to introduce you as I know they have a great weekly yoga class".

4. Staff support

Standards

staff have the practical and emotional support they need to remain compassionate, understanding and emotionally available. This is evident at every level of the organisation and underpinned by HR policies

ward leaders have the skills and training to foster a compassionate culture on the ward

freedom to speak up systems are in place for staff to raise concerns and be heard

staff experience is systematically measured and used to improve care

reflective practice is mandatory for all staff providing care on the ward, regardless of role

we have enough skilled staff on the ward to deliver safe and therapeutic care

staff know spending time with patients is a measurable priority, and that administrative tasks are never prioritised over providing compassionate care

What these standards mean in practice

We understand that safe and high quality inpatient mental health care relies on staff being alongside people in a lot of pain and distress. Witnessing human distress every day can take its toll on staff wellbeing, and therefore their ability to provide a compassionate response. We are committed to providing all our ward staff with the right practical support to protect their time to care, and with the right emotional support so that they can nurture the people they are working with as well as themselves [ 19].

This means staffing levels are safe for everyone, and staff have up-to-date, co-produced and meaningful training, and accessible, trauma-informed and culturally sensitive HR policies, including considering staff groups who experience inequalities ( NHS Workforce Race Equality Standard, Workforce Disability Equality Standard, LGBTQ+ [ 22]).

"Incorporating a compassionate and restorative approach within supervision has been shown to have good outcomes for both staff and service users. For example, the use of a restorative model places value on how participants respond emotionally to the work of caring for others, a key component in the current healthcare climates.

The Professional Nurse Advocate (PNA) programme delivers training for registered nurses in restorative supervision across England." [ 19]

Staff know themselves and recognise that reflection, self-awareness [ 23] and engaging with people are critical to delivering safe, therapeutic care. All staff working with people on the ward have a safe space that is open, supportive and honest to process their own feelings.

Mandated spaces run by trained facilitators and opportunities for reflective practice are built into the ward routines and meetings for all staff, and rotas ensure all staff can attend on a regular basis. Leaders model supportive and reflective leadership, and reflective practice is present at all levels in the organisation.

In line with the Nursing and Midwifery Council code of conduct and NHS England's combatting racial discrimination against minority ethnic nurses, midwives and nursing associates policy, we identify and challenge all forms of racism and create an environment where all staff are treated as individuals and with dignity and respect.

We commit to the ward having visible leaders who are highly skilled communicators and can build and maintain a compassionate culture that is culturally competent, and take action when there are concerns. We encourage all staff to speak up if they have concerns and we ensure they feel safe to do so through supportive organisational systems.

Staff understand and are trained in how to communicate effectively with people who have differences in speech, language and communication needs. They are experienced in using a diverse range of communication methods and engage support from specialist speech and language therapists to further develop their skill in the different methods, so they can offer safe and therapeutic care to all patients, regardless of communication and interaction styles.

5. Equality

Standards

the organisation understands its local population and takes action where certain groups are over- or under-represented in services. And where outcomes for particular groups are poor, we take steps to mitigate these and share learning

patient experience and outcome measures are captured and analysed by protected characteristics (including for levels of restrictive practice)

the organisation fosters connections with local community services, VCSE providers and other statutory organisations to take a collaborative approach in identifying and addressing health inequalities across the whole care pathway

the organisation uses tools such as the Patient Carer Race Equality Framework (PCREF) and Advancing Mental Health Equality (AMHE) Framework to eliminate disparities in access, experience and outcomes

the organisation ensures it meets Equality Act (2010) duties to people with a learning disability or who are autistic, and that their wider human rights are respected and protected [24]

mandatory ongoing training for staff covers inequality and there is regular reflective space (see also Staff support) to discuss equity, intersectionality and impact of own identity

the organisation's workforce and leadership is diverse and inclusive, and reflects the diversity of the community it serves. Leaders take action to address any workforce inequality

Note on intersectionality

We recognise that who people are, and how society responds to them, is shaped by their individual rich and complex mix of identities and experiences. A person's experiences within systems of inequality - from race, ethnicity, gender, sexual orientation, disability, poverty, age, diagnosis and other forms of discrimination - are cumulative and impact on how a person is treated on a ward, their outcomes and experience.

We must see beyond individual oppression and inequalities by making space to consider the complexity of people's identities and understanding that people are affected in different ways. For example, a young black woman experiences high levels of restrictive practice during her inpatient stay. Rather than attempting to disentangle how each characteristic leads to this discrimination and inequality, we must explore how her gender, race and age intersect to impact on her experiences of inpatient care.

A recent Race and Health Observatory report identified that the average age of death is 34 for people from a minority ethnic community who have a learning disability; that is over 25 years younger than their white British counterparts. This intersectionality of race and learning disability is another example of how we must start to look at people's lives differently.

Alongside the protected characteristics in the Equalities Act 2010, we suggest thoughtful consideration of the intersectionality between:

looked after children

young carers

homelessness

drug and alcohol dependence

refugees

people in contact with the criminal justice system

people who experience domestic violence

people who identify as trans*

The wheel of power/privilege is a useful tool to promote conversations about intersectionality. While it does not weight the individual characteristics, it facilitates an understanding of the complex interplay between people's many different characteristics and experiences.

What the standards mean in practice

Our organisation/ward is inclusive; we value difference and do not agree with othering. We respect all people as citizens and valued members of their community. We are here for everyone when they need us, and understand how their background, protected characteristics, health conditions and where they live shapes who they are as people.

We take a systematic approach to understanding the communities we serve, who is over- and under-represented in our service, who is discriminated against and/or who has poorer experiences and outcomes. We take clear action in partnership with marginalised communities to address discrimination and inequalities in our service, and monitor the impact of our actions.

We measure patient experience (both quantitatively and qualitatively) through an equalities lens, and we prioritise these findings over activity-related data in determining our actions. We recognise that existing patient feedback mechanisms may not feel safe and trusted by all patients groups and therefore invest in patient and carer feedback mechanisms for racialised communities in line with the PCREF.

We are culturally competent and take a range of actions to counter systemic racism. Our focus is wider than increasing access for racialised groups, and we ensure everything we do is culturally sensitive by drawing on the PCREF to support cultural change across our services.

We are inclusive and accessible for people with a learning disability. We recognise our role in communicating with the person in a way that makes sense to them and take a strengths-based approach to supporting people.

We are autism-informed. We are aware of the prevalence of autism and neurodivergence in the population we serve and uphold our legal duty to ensure our environment and approaches accommodate autistic people [ 25].

We do not discriminate against people because of their diagnosis, particularly those given a diagnosis of personality disorder (PD). We do not separate people we have labelled 'PD' from those we understand have a serious mental illness, or use the label to deny people access to care and support (see section 6 Avoiding harm).

We do not make assumptions about people's gender or their pronouns. We are trans*-inclusive and respect trans people's choices on where they would like to receive treatment [ 26].

We provide age-appropriate care and treatment to children and young people, with staff trained and competent in understanding and responding to their specific developmental needs.

We provide a safe and accessible environment for trauma survivors, including of childhood sexual abuse and sexual violence, to disclose and access support as needed.

Three clear messages from the 2017 NHS England-commissioned project ' Black Voices ' capturing the voices of 40 Black and Black British men detained in mental health secure care were:

1. Decision-makers and staff lack understanding of how experiences of multiple disadvantage and discrimination contribute to admission to secure care.

2. Many want someone to talk to who can empathise, acknowledge and understand their specific experiences as Black African and Caribbean men, such as a peer worker or advocate.

3. Black men can find it difficult to engage in conventional programmes such as advocacy services, as they are not confident that these services are sufficiently aware or sensitive to their needs as Black men.

We recognise the current circumstances of many of those who face multiple disadvantages will have been shaped by long-term experiences of poverty, deprivation, trauma, sexual violence, abuse and neglect. Many also face racism, sexism and homophobia [ 27]. We understand these inequalities can intersect in different ways, and lead to homelessness, substance misuse, domestic violence, contact with the criminal justice system and mental ill health. We recognise the particular need for services to work collaboratively for those with multiple disadvantages.

6. Avoiding harm

Standards

we acknowledge and avoid the harm and traumatisation that can occur when people are in hospital.

there is a clear pathway of support for patients who have experienced abuse/harm, including access to advocacy

we understand that restraint and coercion is harmful and we only use it as a last resort; that includes the use of blanket restrictions

we do not use mechanical restraint

our inpatient services meet the needs of trauma survivors in crisis

we are trans*-accessible and inclusive (see also Equality)

What do the standards mean in practice

We acknowledge the risk of potential harm and traumatisation from being in a hospital setting [ 28], and seek to avoid this for people in our care. We do this through working to improve care together (as set out in Framework for involving patients in patient safety) and upholding patient rights, not by excluding some people from inpatient services.

"Older trauma survivors can experience re-traumatisation in care settings that provide reminders of traumatic events and/or present limitations to autonomy, choice, and control that are often essential to recovery. In addition, the onset of dementia can trigger the re-emergence of traumatic stress symptoms even where these have been dormant for many years. Common hospital care practices (for example, assisting with toileting and bathing) and environments (for example, locked wards) have been identified as potential sources of distress for older trauma survivors." [ 29]

We validate, respond to and work to mitigate all forms of harm/traumatisation, both those that are significant and those from the everyday experiences of treatment on a ward that are inherent in inpatient settings; for example, being among distressed strangers and away from home. We understand the harm some of our practices can cause - for example, sectioning, restraint, seclusion and coercion - and that they can compound people's previous trauma, oppression and/or experience of racism. We seek to use the least restrictive practices and only use them as a last resort, proportionately and in line with the law. We reflect together regularly as staff and patients about the way we use restrictive practices. We understand that both action and inaction can be harmful, and seek never to neglect people; we do not exclude based on diagnosis and we do not misuse the Mental Capacity Act (2005) to deny access to support.

We reduce our use of restrictive practices for all patients, keeping under close review patient groups that we know are at greater risk of avoidable harm; those subject to restraint inequality. These include trauma survivors, people who have been given a diagnosis of personality disorder, autistic people, people with a learning disability, people from racialised communities and people from LGBTQ+ communities. We provide trauma-specific support for people who have experienced trauma and abuse, and we connect with community-based services to provide continuity in this support and care.

"Ensure people are not inadvertently excluded because of service thresholds, positive risk and/or diagnosis." [ 19]

When people or their families tell us they have been harmed while an inpatient, we hear and believe them, and have robust mechanisms to report harm and take appropriate action. We are accountable for any harm that occurs. We also have an independent support pathway for patients who are harmed so they can access support outside the trust if this is their preference. We raise safeguarding concerns with the local authority as necessary and/or support people to raise these themselves, ensuring access to independent advocacy where safeguarding reviews or enquiries take place.

7. Needs led

Standards

we are needs-led, not diagnostically driven

people are supported and encouraged to define their needs

the MDT respects people's individual understanding of their distress

we validate patients' feelings, and respect their culture, values and beliefs

we take a capabilities approach and recognise that everyone has something to offer

we meet the needs of people's chosen support network

patients' needs and wishes are listened to in the admission and discharge process

What the standards mean in practice

Our services are set up with the prevalence and impact of trauma and adversity in mind. We believe what people tell us has happened to them and are equipped to offer a range of specific trauma interventions in response.

We strive to deliver inpatient care that meets people's individual needs and in this we care about what matters to them. We do not rely solely on diagnosis or 'clusters'. We respect people's individual understanding of what is happening for them. While we may have our own framework or worldview to understand why people are in hospital (biological, medical, genetics, psychology, social, trauma, adversity, lifestyle, spiritual), we remain curious about their individual understanding and respect their right to make sense of themselves, and to reject ideas they consider are harmful to them.

When people may be experiencing a different reality to those around them, through hearing voices or experiencing unusual beliefs, the care team can find it more challenging to achieve a shared understanding with the person. Staff are supported to work compassionately with the person to establish their preferences (see also 3. Relationships).

We take a holistic capabilities approach to understanding people's needs and strengths, recognising all aspects of what brings meaning and value to people's lives [ 30]. We recognise the importance of fundamental needs like safe housing, financial security and physical health, and of the connections and relationships in people's lives. We are also sensitive to people's cultural identity and responsive to their spiritual needs and beliefs; what matters and makes sense to them. We care about the activities that are meaningful to the individual and help them build a life worth living, whether they be creative, leisure, education, volunteering or employment.

When people leave hospital their physical health should be at least as good, if not better, than when they were admitted. Staff are trained to understand patients' physical health and care needs, including those of people with a learning disability or who are autistic, and in the routine day-to-day management of conditions such as cardiovascular disease, epilepsy, sleep apnoea and diabetes. They know where to get advice on caring for someone's physical health, and people have access to a GP and more specialised care for their physical health. Staff also understand how to support and actively engage patients to manage their own long-term conditions and physical health while in hospital. Food options are always healthy and nutritious, and reasonably adjusted physical activity is always available.

"It would have been good to have a member of staff whose job is just focused on relatives and gets to know them well to support them. There are some very good staff but some don't seem to have the time for families." [ 31]

Staff are supported to respond to the needs of people's chosen support network, including what help they may need with their own wellbeing. If the person does not want their support network involved in their care, staff take a common-sense approach to communication with the support network, recognising both the need to protect patient confidentiality and to show compassion to those who support the person.

8. Choice

Standards

patients always have the choice to be present at meetings about them

we adhere to the evidence-based approach of Open Dialogue and its key principles

patients are supported to be involved in the decisions about them

patients have choice in everyday decisions

patients have the choice to collaborate in the writing of their notes and/or have access to their notes so that they know what has been recorded about them at any point during their inpatient stay

patients have informed choice over their preferred treatment and who is involved in their care

Where legislation overrides personal choice, this is explained in a clear and transparent way

patients have the choice to be supported by people who know them well, by an advocate or by a peer worker

What the standards mean in practice

We understand that people often feel disempowered by coming into hospital, and we commit to prioritising patient choice over the needs of the service. People who use our services have control over everyday decisions, such as where they eat, what clothes they wear, when they spend time in the fresh air, who they spend time with and what time they go to bed.

Our expectation is also for everyone to have informed choice in every aspect of their care, including: admission and discharge; where they receive support; what treatments they receive; and who is involved in their care (the staff who work with them and their support network). People can choose to lead on producing a formulation of their distress and which staff members they would like to collaborate with in this process.

In line with the NICE guideline on shared decision making [NG197], we support people on the ward to make shared decisions about their care, working in an open and consistent way with their families, carers or advocates where the person wishes them to be involved. We use different communication approaches to support people's understanding of decisions about them.

In line with the 7 Open Dialogue principles, we commit to never holding meetings (including ward rounds) about people on the ward without giving them the choice to be present; and the choice to work with staff on the completion of their notes or the option to access their notes at any point during their inpatient stay [ 32, 33, 34]. Any difference in opinion between staff and the person is described in the notes.

Where choice needs to be balanced with safety, developmental needs for children and young people or the best interests for people with a learning disability or autistic people, we consider individual needs and capacity relevant to the specific situation. Best interests decisions are person-centred, and well-communicated and well-documented.

Where people come into hospital against their wishes or where their care and treatment is stipulated by the Ministry of Justice, safeguarding or duty of care, we are transparent with them about how this can limit personal choice. Where choice in treatment is removed, we commit to work with the person to increase the choice they have in other aspects of their care. We are honest that we are denying choice and do not frame it as a shared decision or collaboration. This includes where we need to deny the choice to attend meetings or see own notes; and in such circumstances we seek to include the person's views in the meeting and notes.

We embrace the contribution of advocates and peer advocates (see Figure 1 below), encouraging advocacy colleagues to be present within our services. We are proactive in ensuring patients know their rights, including under the Mental Capacity Act, and the advocacy available to them.

Figure 1: What people want from their advocate (reproduced with permission from NDTi A review of advocacy)
Image description: Diagrammatic representation of advocate qualities from the person's perspective: is independent; is confident, skilled and knowledgeable; listens to family; upholds person's rights and entitlements; understands the system and what's possible; provides long-term, person-led, holistic support; has strong communication skills with professionals; has strong communication skills with the person they advocate for; builds relationships and rapport; is a named person and easy to access.

"I am a peer supporter with an NHS Foundation Trust. I help others to speak up using my own experience of being a self-advocate, having a learning disability myself.

When I was in a secure mental health hospital it was quite hard to speak up. When I asked to see an advocate people thought I wanted to make a complaint. But I wasn't complaining, I just wanted help to understand my rights and speak up in my meetings. Some of my advocates were alright but some were just a 'tick box exercise'.

I think advocacy is so important in secure services and in the community to show the person that their voice and opinion is valued and listened to. When I had a good advocate they came to my meetings, valued my opinion and put my views across to other people. People listened to my advocate.

Mental health advocates need to protect people's rights, not be afraid to challenge the hospital and not get too close to the service, so they stay independent. They should have an open mind and probably need more training so they can support people with a learning disability and autistic people better.

I am out of hospital now and I do have an advocate in the community, but I don't rely on them. I use my self-advocacy group to give me strength to speak up for myself and this is really important especially for people who do not have close family or friends. I also help to run focus groups with patients in secure services, to help people to get their voice heard and talk together."

9. Environment

Standards

the environment is inclusive and accessible, including through making reasonable adjustments where appropriate

the environment is autism-informed, trauma-informed and sensory friendly

comfort is prioritised alongside the space being clean and hygienic

to prioritise relationships, there are no locked staff offices on the ward

all people have open access to outdoor and green space

the ward environment and procedures foster a sense of community, for example eating together

the environment has been co-designed with people with lived experience and the needs and preferences of patients are evident in it

What do the standards mean in practice

We understand the impact the hospital environment can have on patient and staff wellbeing. We adapt our ward environment (thinking about sight, sound, smell, taste, touch, temperature, proprioception, interoception and pain [ 35]) to meet the needs of those admitted - cultural, disability and sensory needs (particularly for autistic people and trauma survivors) [ 25], ensuring it enables everyone to access the care they need and prevents adverse health outcomes.

"...our experience during site visits showed that if patients' basic needs are met, and morale is positive, the condition of the physical environment itself becomes less important. However, in a negative culture with low morale, the maintenance issues and limitations and inadequacies of the physical environment are magnified."

Midlands Clinical Senates Report on Therapeutic Inpatient Environment.

We want our inpatient space to be as soothing and comforting as possible for people who are often at their most vulnerable, and for it to reflect how we value staff and patients. This means the ward is clean, hygienic, well maintained and as least restrictive as possible, and everyone has access to outdoor and green spaces. It also means that the ward design both fosters a sense of community and protects people's right to privacy, dignity and a family life, and promotes connection with life outside hospital. Wards need spaces suitable for families to visit, and children and young people's services need spaces for education and, where possible, for families to stay overnight.

Staff have a staff room on site that is equipped to allow them to take a relaxing and peaceful break, but there are no spaces where staff are shut away from people on the ward, such as locked staff offices. Staff are present in communal areas and available to spend time with patients and families for most of every shift. There are spaces for therapy, for private conversations and for visitors.

"One of the key things about the mother and baby unit that made it a more healing experience was that staff and patients cooked their meals together and ate together in a shared kitchen. This supported really normal and human conversations where I was seen and understood as a woman and a mum, not a diagnosis. It also meant the food was much better than the re-heated beige food served on acute wards!"

Person with lived experience of inpatient care in a mother and baby unit.

We recognise the importance of food for people's wellbeing and cultural identity. We provide a variety of nutritious food options, which meet people's physical health needs, cultural and religious requirements and preferences. Staff and patients have opportunities to cook and eat together.

10. Things to do on the ward

Standards

people are supported to spend their time doing activities they enjoy

patients decide which activities are on offer, including those that are culturally appropriate

wards collaborate with VCSE and lived experience partners to deliver those activities

activities support physical wellbeing

What the standards mean in practice

People admitted to our wards need the chance to do some of the things that they would do at home; many aspects of normal life should not cease on admission. People also need things to do to avoid boredom exacerbating their distress.

"Day to day life on the ward should as far as possible maintain a sense of normality and a connection to the outside world."

"Life on the ward can often feel like living in a clinical bubble. But we need to be able to feel hopeful about what our future could look like outside hospital."

"There should be a range and choice of regular activities and things to keep us occupied. This is so beneficial to help lift mood, find positivity, make connections with others and reduce loneliness. Boredom makes us more likely to dwell on negative or intrusive thoughts."

Statements gathered by Common Room as part of the Children and Young People's Quality Improvement Taskforce, 2023.

We have a clear, structured activity programme co-designed by people on the ward and we offer a range of patient-requested distraction and soothing activities, including those requested by people from racialised groups and/or other marginalised backgrounds. We work with local VCSE partners and the community to support this range of activities.

"A small number of women had been involved in charitable fundraising events and spoke powerfully about the positive impact this had on their hope for the future and on their sense of self-worth and purpose." [ 19]

We can evidence that we provide opportunities for people to do things that matter to them, for example cooking, shopping, watching films, exercise. These activities are available 7 days a week, not restricted to 9am to 5pm [ 36], but should a person wish to watch TV or listen to music, for example, we facilitate this in a way that does not unduly compromise the comfort and wellbeing of others. We also understand that blanket restrictions can harm some people and we are committed to prioritising personalised choice over and above restrictions.

"The best activities are person-centred and have the flexibility to fit the changing and diverse range of needs that different people on the ward have."

"When thinking about activities, ask patients 'what you are interested in'. Try and meet people where they are - even if they want to be alone in their room, you can offer them ways to listen to music, or read, or journal, and not just see it as withdrawing."

"What is right for one person will be different for someone else; what is a meaningful or enjoyable activities is subjective, so you are never going to get it perfect but it's about trying to connect. A good way of getting it right is to have variety so you can reach a lot of people."

Lived Experience Advisory Group members for 'Co-producing activities that support health, recovery and mental wellbeing for people with psychosis on acute mental health wards and beyond.' Researchers: Simpson, A., Foye, U., Regan, C., Brennan, G., Williams, J., Funder: London, Maudsley Charity.

People can participate in physical exercise every day and are encouraged to do so, by having the benefit explained to them in a meaningful way. A person's mental state and staff availability are never used as reasons to deny access to physical activity.

We understand the value of people's support networks. We are committed to being flexible in accommodating visitors. We facilitate access to culturally appropriate hairdressers, faith-based healers, ministers, prayer facilities and materials with which to conduct religious rituals, and other spiritual support networks.

11. Therapeutic support

Standards

people have access to culturally sensitive support and treatment that is helpful

people can choose their preferred therapy from a range of options, including trauma-specific therapy

people have access to support around their social needs, including to maintain links with any community-based health and social care services and to plan for transition

What the standards mean in practice

We understand that being admitted to an inpatient setting can be a frightening and traumatising experience, and we are committed to making our services as therapeutic as possible.

"Mental health services take an evidence-based approach to treatment, but sometimes the simplest things like kindness and compassionate care are also extremely important for an individual's care and recovery." [ 37]

We never leave people in despair for any prolonged period, including during evenings and weekends, to repeatedly bang their heads on the walls or hit, bite or scratch themselves. They are always taken seriously and receive a compassionate and therapeutic response, one that does not rely only on medication.

We know that people from racialised communities and children and young people are often over-medicated rather than offered therapeutic support and ensure we consider and evidence how we mitigate this.

We ensure that therapeutic, sensitive support is available for people to access at any point during their inpatient stay, not just between the hours 9am to 5pm or at key points of stress such as admission and discharge, and can evidence how we provide this. We build strong relationships with those supporting people in the community, to ensure our patients are supported after discharge.

"There should be regular therapeutic intervention available to enable us to build skills to support our recovery. This intervention should be reviewed regularly with us and tailored to our individual needs."

Young person with inpatient experience.

We give people choice in the evidence-based therapies and interventions they receive, especially trauma-specific therapies. We ensure our therapeutic offer is culturally appropriate and adapted to the needs of different groups of people, including people with a learning disability, autistic people and children and young people.

Where we cannot give people choice in therapy - for example, because completion of certain therapeutic programmes is a condition of admission as a restricted patient - we increase choice in other areas, from things to do on the ward, to social supports and relaxation approaches.

Where a person lacks the capacity to make an informed decision about the treatment they receive, we work with them and their support network (as appropriate) to consider what has worked well for them in the past, and what their wishes and preferences may be. Where we give treatment without the person's consent or against their will, we are clear that this has not been a collaborative decision.

We ensure that social support is part of the therapeutic offer, including help accessing things like benefits, housing, vocation and food. We also work with VSCE partners to ensure that people are supported on the ward with issues relating to domestic and sexual violence, distress around being LGBTQ+, autistic or from a racialised and/or other marginalised groups. We provide resources and support to encourage a variety of peer support groups to meet on our ward to enhance our therapeutic offer to people.

12. Transparency

Standards

we are honest with patients about our decision-making

we have a regularly reviewed, co-produced charter that clearly sets out values and expectations

the organisation has a transparent, compassionate, safe and responsive complaints process

we are alert to how closed cultures can develop and take steps to avert this in partnership with people and families

independent organisations and advocacy are welcomed onto the ward

we are transparent about the names, roles and responsibilities of everyone working on the ward

What the standards mean in practice

We acknowledge that by the very nature of mental health hospitals, staff on the ward have power over patients. We commit to ensuring we have an open culture, recognise the value of having a welcoming environment in maintaining this culture, and take steps to mitigate the risk of closed cultures [ 38] developing. We welcome people from other organisations and a person's support network and community onto the ward (in line with the person's wishes). We recognise that services caring for people with a learning disability and autistic people are at a higher risk of a closed culture [ 39].

Staff, patients and their families meet daily to talk openly about their experiences of being on the ward, and we recognise this engagement as an important mitigation to closed cultures. We also regularly hold inclusive, shared learning events across our own and other organisations, and facilitate people on wards in different services to connect where it is safe for them to do so.

We are open and transparent about what happens on the ward and the care we provide.

"Coming into the visitors' centre is such a difference. The staff are just brilliant. Friendly and kind. They smile and always make time for you. I can't tell you how much difference this means to me." [ 31]

We know that being on a ward with strangers can be frightening, so we try and familiarise people with who the staff are (including agency staff, advocates and visiting VSCE staff) by having visual displays showing, ideally, a photograph of each staff member along with their name, role, responsibilities and some information about them (see Safewards' Know each other guidance). We also have freely available information describing the different mental health, learning disability and autism services within the organisation.

We take particular care to communicate information at times of transition, ahead of admission and in the run up to discharge from the ward. All our communications are accessible to their recipients and available in a range of formats to meet people's needs.

We have a safe, culturally appropriate and accessible complaints and advocacy process for both staff and patients so they can escalate concerns without fear of this negatively impacting on them. We clearly signpost to our complaints process, and can evidence how we help people to access it, especially those who do not communicate in traditional ways, such as children or people with a learning disability.

We embrace advocacy services as an integral part of the service to patients and ensure patients are supported to access independent advocacy where they wish to. We ensure marginalised groups, for example people with a learning disability and autistic people have the same access to advocacy as other groups [ 40], and that patients have access to culturally competent advocacy.

We offer people a range of ways to share their experiences of being on our wards, including independent options, to acknowledge that sometimes people do not want to give feedback directly to staff. We have a clear process and pathway to support patients who have been harmed on our wards and no longer feel safe in the organisation to access independent support, both legal and psychological.

References

1. Braithwaite J, Herkes J, Ludlow K, et al (2017). Association between organisational and workplace cultures, and patient outcomes: systematic review. BMJ Open 7(11).

2. West M, Dawson J (2012). Employee engagement and NHS performance. The King's Fund.

3. Adams R, Ryan T, Wood E (2021). Understanding the factors that affect retention within the mental health nursing workforce: a systematic review and thematic synthesis. Int J Ment Health Nurs 30 (6): 1476-1497.

4. Dickens G, Picchioni M (2011). A systematic review of the terms used to refer to people who use mental health service: User perspectives. Int J Soc Psychiatry 58 (2): 115-122.

5. Evans J, Rose D, Flach C, Csipke E, Glossop H, Mccrone P, Craig T, Wykes T (2012). VOICE: developing a new measure of service users' perceptions of inpatient care, using a participatory methodology. J Mental Health 21(1): 57-71.

6. Holley J, Gillard S, Gibson S (2015). Peer worker roles and risk in mental health services: A qualitative comparative case study. Commun Mental Health J 51: 477-490.

7. National Advisory Group on the Safety of Patients in England (2013). Berwick review: A promise to learn - a commitment to act: improving the safety of patients in England. Department of Health and Social Care.

8. Griffiths J, Lever Taylor B, Morant N, et al (2019). A qualitative comparison of experiences of specialist mother and baby units versus general psychiatric wards. BMC Psychiatry 19(1): 401.

9. National Survivor User Network (2021). Lived Experience Leadership - Mapping the Lived Experience Landscape in Mental Health.

10. National Collaborating Centre for Mental Health (2020). Standards and guidance to improve sexual safety on mental health and learning disabilities inpatient pathways.

11. Rooney, C (2009). The meaning of mental health nurses experience of providing one-to-one observations: a phenomenological study. Journal of Psychiatric and Mental Health Learning 16(1): 76-86.

12. Gill F (2014). The transition from adolescent inpatient care back to the community: Young people's perspectives. London: University College London.

13. McCormack B, McCance T (2010). Person-centred nursing: Theory, models and methods. Oxford: Blackwell.

14. NHS England position on serenity integrated mentoring (SIM) and similar models

15. Mental health blog (2022). Exclusion, coercion and neglect: the neoliberal co-option of positive risk-taking.

16. NICE (2022). Self-harm: assessment, management and preventing recurrence [NG225].

17. Pashley S, Denison S, Moore H ( April 2018). Exploring the lived experience of women in secure care services. National conference: Women in Secure Care, London

18. Duncan BL, Miller SD, Wampold BE, Hubble MA, eds (2010). The heart and soul of change: Delivering what works in therapy, 2nd edn. Washington DC: American Psychological Association.

19. Gilburt H, Rose D, Slade M (2008). The importance of relationships in mental health care: A qualitative study of service users' experiences of psychiatric hospital admission in the UK. BMC Health Serv Res 8: 92.

20. NHS England (2022). The mental health nurse's handbook

21. Liberati E, Richards N, Ratnayake S, Gibson J, Martin G (2023). Tackling the erosion of compassion in acute mental health services. BMJ 382: e073055.

22. Kain K, Terrell S (2018). Nurturing resilience: helping clients move forward from developmental trauma, an integrative somatic approach. North Atlantic Books, p229.

23. The King's Fund (2023). LGBTQ+ staff and patients deserve better from the NHS.

24. Kirsten J (2008). Exploring self-awareness in mental health practice. Mental Health Practice 12(3): 31-35.

25. NHS Improvement (2018). The learning disability improvement standards for NHS trusts.

26. Doherty M, McCowan S, Shaw SCK (2023). Autistic SPACE: a novel framework for meeting the needs of autistic people in healthcare settings. British Journal of Hospital Medicine 84(4).

27. Újhadbor R, Chuck E, Gohlan N, et al (2022). recommendations for trans*-inclusive healthcare. King's College London.

28. Making Every Adult Matter. About multiple disadvantage.

29. Thibaut B, Dewa LH, Ramtale SC, et al (2019). Patient safety in inpatient mental health settings: a systematic review. BMJ Open 9: e030230.

30. Couzner L, Spence N, Fausto K, et al (2022). Delivering trauma-informed care in a hospital ward for older adults with dementia: an illustrative case. Front Rehabilitat Sci 3: 934099.

31. Nussbaum M (2011). Creating capabilities: The human development approach. Cambridge, MA: Harvard University Press.

32. NHS England (2018). Carer support and involvement in secure mental health services: A toolkit

33. Pell JM, Mancuso M, Limon S, Oman K, Lin C-T (2015). Patient access to electronic health records during hospitalization. JAMA Internal Med 175 :856-8.

34. Woollen J, Prey J, Wilcox L, et al (2016). Patient experiences using an inpatient personal health record. Appl Clin Inform 7: 446-60.

35. Vawdrey DK, Wilcox LG, Collins SA, et al (2011). A tablet computer application for patients to participate in their hospital care. AMIA Annu Symp Proc: 1428-35.

36. NHS England (2023). Sensory-friendly resource pack.

37. NICE (2011, last updated 2019). Quality standard [QS14]. Service user experience in adult mental health services.

38. Moore P (2022). One act of kindness can change another person's future. NHS Voices blogs

39. CQC (2022).Our work on closed cultures.

40. CQC inspections and regulation of Whorlton Hall 2015-2019: an independent review

41. Mercer K, Petty G, NDTi (2023). A review of advocacy for people with a learning disability and autistic people who are inpatients in mental health, learning disability or autism specialist hospitals.

42. Lomani J, Alyce S, Aves W et al, in collaboration with Survivors Voices (2022). New ways of supporting child abuse and sexual violence survivors: A social justice call for an innovative commissioning pathway.

Glossary

Office spaces within the main ward environment that are separated from and closed/locked to patients. This term does not include locked office spaces that are separate from the main ward environment where patients are.

Person, group of people, community or organisation that provides emotional and/or practical support to someone in need. A support network can be made up of family members, friends, colleagues, advocates, peers, volunteers, health and social care professionals, or supportive online forums or social networking sites.

Appendix: design group membership

Tim Kendall, Co-chair and National Clinical Director for Mental Health, NHS England

Cassie Lovelock, Co-chair and Expert by Experience

Khudeja Amer-Sharif, Expert by Experience

Tom Ayers, Director, National Collaborating Centre for Mental Health, Royal College of Psychiatrists

John Baker, Chair of Mental Health Nursing, University of Leeds

Kelly Barker, Chief Operating Officer, Bradford District Care NHS Foundation Trust

Dan Beale-Cocks, Expert by Experience

Joanne Bosanquet, CEO, Foundation of Nursing Studies

Geoff Brennan, Safewards Clinical Supervisor, King's College London

Mel Bruce, Psychologist, Specialist Advisor Clinical Quality, Learning Disability and Austism Programme, NHS England

Mary Busk, Expert by Experience

Paul Calaminus, Senior Programme Manager - Quality Transformation, NHS England

Prathiba Chitsabesan, National Clinical Director for children and young people's mental health; Consultant Child and Adolescent Psychiatrist

Jill Corbyn, Founder and Director, Neurodiverse Connection

Marie Crofts, Chief Nurse, Oxford Health NHS Foundation Trust

Rebecca Daddow, Head of Adult Secure, National Specialised Commissioning, NHS England

Charmaine DeSouza, Chief People Officer, Oxford Health NHS Foundation Trust

Sahil Dodhia, Senior Project Manager and Expert by Experience, NHS England

Caroline Donovan, National Advisor to Quality Transformation Programme

Conor Eldred-Earl, Expert by Experience

Mark Farmer, Expert by Experience

Alex Hamlin, Lead Psychologist for Learning Disability Services, Humber Teaching NHS Foundation Trust

Helen Hardy, Head of Mental Health, East of England Region, NHS England

David Harling, National Deputy Director of Learning Disability Nursing, NHS England

Liz James, Head of Nursing for Positive Practice, Southern Health NHS Foundation Trust

Stephen Jones, Professional Lead for Mental Health, Royal College of Nursing

Elizabeth Kirby, Senior Project Manager, Quality Transformation, NHS England

Aji Lewis, Expert by Experience

Jo Lomani, Senior Project Manager and Expert by Experience, NHS England

Kate Lorrimer, Deputy Head of Quality Transformation (Quality of Care), NHS England

Sarah Markham, Expert by Experience

Tim Mellard, Matron, South West Yorkshire Partnership NHS Foundation Trust

Salli Midgley, Director of Nursing, Sheffield Health and Social Care NHS Foundation Trust

Sam Mongon, Head of Transformation, Avon and Wiltshire Mental Health Partnership Trust

Debra Moore, Deputy Head of Quality Transformation (Redesign), NHS England

Maria Nelligan, Interim Executive Director of Clinical Transformation, Greater Manchester Mental Health NHS Foundation Trust

Peter Oakes, Psychologist

Mary Ryan, Expert by Experience

Ashok Roy, Consultant Psychiatrist, LD, Coventry and Warwickshire Partnership Trust

Melissa Simmonds, Race Equity Community Leader, Sheffield Health and Social Care NHS Trust

Alan Simpson, Professor of Mental Health Nursing, King's College London

Dwayne Smith, Expert by Experience

Lade Smith, President, Royal College of Psychiatrists; Consultant Psychiatrist

Sal Smith, Expert by Experience

Tasha Suratwala, Expert by Experience

Claire Swithenbank, Regional Head of Learning Disability and Autism, North West Region, NHS England

Peter Thompson, Director College Centre for Quality Improvement, Royal College of Psychiatrists

Giles Tinsley, Programme Director for Mental Health, Midlands Region, NHS England

Kati Turner, Expert by Experience

Jacky Vincent, Executive Director of Quality and Safety (Chief Nurse), Hertfordshire Partnership NHS Foundation Trust

Emma Wadey, NHS England, Head of Mental Health Nursing

Ellie Walsh, Navigo

Gareth Watkins, Expert by Experience

Mark Weaver, Chief Medical Officer, Black Country Healthcare NHS Foundation Trust

Nicky Windle, Senior Programme Manager - Quality Transformation, NHS England

Anne Worrall-Davies, Interim National Clinical Director, Learning Disability and Autism Programme, NHS England

Debbie Wood, Gareth Watkin's co-worker

With thanks to the many additional people who provided feedback on the draft versions.

Publication number: PRN00826

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Culture of care standards for mental health inpatient services

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In 2022, the Mental Health, Learning Disability and Autism Inpatient Quality Transformation Programme was established to support cultural change and a new bold, reimagined model of care for the future across all NHS-funded mental health, learning disability and autism inpatient settings.

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Social Work Toolkit part 2 (resources, theory and assessment tools)

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Social Work Toolkit part 2 (resources, theory and assessment tools)

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The Social Work Toolkit is an online resource that brings together a wealth of content to help social work students develop their knowledge, skills and confidence.

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You don't need to have "capacity" to vote!

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Capacity and voting (election/ ballot/ vote)

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Capacity and voting (election/ ballot/ vote)

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Joint Parliamentary Response to MHA Bill March 2024 (Mental Health Act legal updates/ changes)

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Joint Parliamentary Response to MHA Bill March 2024 (Mental Health Act legal updates/ changes)

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Presented to Parliament by the Secretary of State for Health and Social Care by Command of His Majesty.

March 2024

CP 1036

ISBN: 978-1-5286-4428-0

Introduction

The Mental Health Act 1983 governs the compulsory detention and medical treatment of people with severe mental illness, people with a learning disability and autistic people for their own safety or for the protection of others. In 2018, a landmark independent review, chaired by Professor Sir Simon Wessely, found that the act could be reformed in order to deliver a modern mental health service that respects the patient's voice and empowers individuals to shape their own care and treatment.

The draft Mental Health Bill contains proposals to reform the Mental Health Act ( MHA) and provide a stronger system updated for the 21st century. These proposals would:

provide for enhanced protections and support for people with severe mental health needs

strengthen their voice, choice and rights

support work underway to address the racial disparities that have too long been part of the way the act has been used

The draft bill contains provisions to:

tighten the criteria which govern when someone can be detained ('sectioned') under the act - to ensure detention only happens where strictly necessary, and where there is a clear therapeutic benefit

further limit the extent to which people with a learning disability and/or autistic people can be detained and treated under the act and support such individuals to live fulfilling lives in their community

give patients, where possible, greater involvement in decisions concerning their own care and treatment, and rights to appeal their detentions more frequently

strengthen and improve the statutory roles which protect and support those who are detained, by increasing legal rights to access independent mental health advocates, and by allowing patients to choose their own 'nominated person' (NP) rather than just be assigned a 'nearest relative'

support offenders with serious mental health problems to access the care they need as quickly and early as possible, and improve the management of those patients subject to a restriction order (for the purposes of public protection)

Pre-legislative scrutiny process

The draft Mental Health Bill was published on 27 June 2022. The Joint Committee on the draft Mental Health Bill was appointed on 19 July 2022, chaired by Baroness Buscombe, and reported on its pre-legislative scrutiny of the bill on 19 January 2023. The committee made 55 recommendations, not just in terms of amending the bill itself, but also to help secure its successful implementation.

The government would like to thank the committee, its chair, members and staff for its careful and considered work scrutinising the draft bill. We are also grateful to all the stakeholders who gave or provided oral or written evidence.

The safety and care of mental health patients is of paramount importance, and people receiving inpatient care should expect high quality services. The Department of Health and Social Care commissioned an independent rapid review to explore how government can improve the way data and evidence is used to identify risks to patient safety in mental health inpatient settings. The review was published on 28 June 2023 and the government will be issuing a response.

In addition, the Health Services Safety Investigations Body ( HSSIB) has launched a national investigation into mental health inpatient settings as one of its first priorities. The investigation will identify risks to the safety of patients and the HSSIB will seek to address those risks by making recommendations to facilitate the improvement of systems and practices in the provision of mental health care in England. The aims of the investigation include learning from inpatient mental health deaths to improve patient safety. We have carefully considered our responses to each of the recommendations made by the committee. These are set out in the subsequent response.

In taking forward the committee's recommendations, there as some areas where changes will need to be made to the draft bill prior to introduction. We have also set out in our response areas which require further consideration and policy development prior to being ready to introduce the bill. We will seek to introduce a revised bill when Parliamentary time allows.

Although the committee did not number its recommendations, we have chosen to number them in the order they appeared in its report. This is intended to be helpful, and to provide clarity in those instances where we have responded to recommendations out of their original order.

Recommendation 1

To facilitate early engagement with future pre-legislative scrutiny, we recommend that the Cabinet Office's guide to making legislation include wording for bill teams to include in press notices announcing future draft bills. This should advise readers on the upcoming scrutiny process and direct them to where further information can be found. This wording should be agreed with officials in the Scrutiny Unit in both Houses of Parliament.

Government response

The government accepts this recommendation and is grateful to the House Authorities for engaging on the wording that will be included in the next revision of the guide to making legislation .

Recommendation 2

We recommend that there should be an ongoing process of mental health legislation reform, leading in the direction of more 'fused' and rights-based legislation and learning from developments elsewhere in the UK and overseas. In advance of this work, the government should look for opportunities to amend the code of practice to improve the justification required for clinical decisions to use the MHA where a patient has decision making capacity and is refusing admission and treatment.

Government response

We welcome the committee's support for reform to mental health legislation. Under the reforms provided for in the draft bill, people will have more choice and influence over their treatment, and detention will only take place when it is absolutely necessary. We will also make legislation and guidance clearer to ensure that people continue to get the protections provided by the MHA when needed. In addition to legislative reform, we will update the code of practice.

These reforms will take time to implement and form part of a system-wide programme to improve mental health services. We will continue to review implementation of the reforms within the bill and will commission independent evaluation of the reforms. The government accepts that we should keep mental health legislation under review, including the matter of fusion and a rights-based approach.

Recommendation 3

Effective handling of complaints is an important part of ensuring patients feel their voices are heard and services improve from a service user perspective. We recommend that the government adopt the Parliamentary and Health Service Ombudsman's ( PHSO) recommendations on streamlining and signposting complaints processes.

The PHSO 's recommendations taken from their written evidence:

the bill should consider proposing that a complaint does not have to be made in writing and instead can be made through other means, such as over the phone or via a video call, to give complainants options in the way they communicate their complaint and experience

the bill should be updated to state clearly what exactly each organisation can and cannot look at in relation to MHA complaints

the bill should introduce mandatory signposting. This would require providers of care under the MHA to provide information about the 4 routes of redress available and what each organisation can specifically look at. These routes are:

tribunal

Care Quality Commission (CQC)

Local Government and Social Care Ombudsman (LGSCO)

Government response

The government agrees with the committee about the importance of the complaints process being accessible and responsive. We will work with CQC and PHSO to establish what steps need to be taken to improve the complaints process.

The draft bill already contains proposed amendments to section 132 and 132A of the MHA and inserts a new section 132B, which will place a statutory duty on hospital managers to supply complaints information to both the patient and their nominated person on a more regular basis. We will provide further guidance on what information should be provided in the code of practice, including information on which is the right body to complain to in respect of particular issues.

Although we are sympathetic to PHSO 's recommendations, the government does not think that legislation is necessary as there are alternative ways of signposting and clarifying the complaints process. We will provide further guidance in the next revision of the code of practice.

Recommendations 4, 10 and 40

Recommendation 4

We recommend that the post of a statutory mental health commissioner should be created, with the support of an office. Their role should include:

being a voice at the national level promoting the interests of those who are detained, or are likely to be detained, under the MHA, and of their families and carers, raising awareness of their needs, and challenging stigma and stereotypes

working in conjunction with the CQC and other bodies to make recommendations on reforming mental health law in the direction of more rights-led and 'fused' legislation

tracking the implementation of the reforms in and associated with this bill, including the provision of data

providing advice and support to service users, their families and carers on their rights and how to navigate complaints processes; working with NHS bodies, the CQC and PHSO to promote best practice in handling complaints

Recommendation 10

We recommend that one of the roles of the commissioner proposed in chapter 2 will be to be a national figure overseeing, standardising and promoting the work of the 'responsible people' proposed above and already in the Mental Health (Use of Force) Act. They should also work with the NHS and independent services, CQC, Equality and Human Rights Commission (EHRC) and Office of the National Data Guardian to produce proposals aimed at reducing inequalities in, and improving data on, the provision of services and use of powers under the MHA.

Recommendation 40

There will be benefits for service users and professionals if as many people as possible nominate their nominated persons in advance of a crisis situation. Earlier in this report we recommended a statutory right to request an advance choice document. We recommend that the choice of nominated person is included in such documents. We also envisage that as part of the mental health commissioner's advocacy and support function, they may wish to promote the value of specifying a nominated person at or soon after the point of diagnosis.

Government response

The committee suggested that CQC 's wide remit, and its regulatory role, might detract from its functions in respect of the rights of mental health patients, resulting in the need for a dedicated advocate or 'consumer champion'. On the contrary, firstly we believe that the wide remit allows it to take a holistic view of the health and social care sector, making it uniquely placed to identify and investigate potential issues. We also feel that its role as a regulator means that it is well positioned to directly follow up on any issues it might find with the powers to intervene where necessary.

Secondly, we feel that, at a 'consumer' level, there are already statutory mechanisms in place to champion the voices of service users, such as independent mental health advocacy ( IMHA) services and Healthwatch England, which is an independent statutory body that is responsible for gathering feedback from service users to improve health and care standards.

Taking all these considerations into account, the government does not believe that a statutory mental health commissioner would add significant value within the framework currently provided by existing bodies. Therefore, we do not intend to take this recommendation forward.

Recommendations 5, 6 and 7

Recommendation 5

We recognise the government's concerns about putting entirely new principles into the MHA and are wary of making complex legislation yet more complex. We believe that there already exists a mechanism to put the principles into the act that meets those concerns. We recommend that section 118 be replaced with a new section, requiring the Secretary of State to draw up the code of practice having regard to and including the principles set out in the independent review: choice and autonomy, least restriction, therapeutic benefit and the person as an individual. The new section should also specify that the principles should inform decisions taken under the act, mirroring the current wording in section 118. This would ensure that the principles endure, inform the operation of the amended act and would require the government to ensure they are reflected in the practical guidance given to professionals on all aspects of how the act operates in practice.

Recommendation 6

We recommend that the replacement for section 118 be placed at the beginning of the amended act. This would reflect the central role of the principles and code of practice in the operation of the MHA in practice. It would make the legislation more accessible and better tell the story of what the amended act is trying to achieve. Placing principles relating to patient choice and least restriction in the legislation before the powers to detain is logical and would send a message to help drive that cultural change ahead of more fundamental reform.

Recommendation 7

The principles that the Secretary of State is required to draw up under section 118 of the MHA that 'inform' decisions under the act do not explicitly include the need to respect racial equality. Whether or not they accept our earlier recommendation about re-writing section 118, the government should amend it so that the list of matters that the Secretary of State must address in the code of practice includes respect for racial equality.

Government response

The government is firmly supportive of the 4 principles that were co-designed with service users during the independent review. These are choice and autonomy, least restriction, therapeutic benefit and the person as an individual.

We are grateful that the committee has recognised the complexities involved with putting new principles in existing legislation and at the same time we do recognise the strength of feeling on this issue.

We maintain the view that, with regard to the principles, the strongest and most effective approach to deliver the impact and change envisaged by the independent review, and to drive culture change in how the act is applied, is to embed them substantively in targeted, specific and practical measures in the act and to give full prominence to the principles in a revised code of practice. The principles have informed every decision we have made when developing new measures in the draft Mental Health Bill.

Given that the act already contains a statutory duty to include a statement of principles in the code, we will ensure that the new principles are clearly set out up front in the next revision of the code of practice, which informs the decisions of those performing functions under the act and will provide guidance as to how the amended act should be applied in practice. This will make it clear to practitioners that the recommended principles should inform all decisions made under the act. We do not consider that replacing the current list of matters required to be addressed by the statement of principles in section 118(2B) with the 4 principles is the most effective means of driving cultural change and ensuring the principles are central in all decisions as to how the act is applied. The express inclusion of respect for racial equality in the list of matters that must be addressed in the statement of principles in the code of practice is also not necessary as this is already a requirement of the Equality Act 2010, to which those carrying out functions under the MHA must already adhere.

Recommendations 8 and 9

Recommendation 8

Improving data collection will be an important part of reducing inequalities, but it cannot be an excuse for a lack of urgent and comprehensive action. There should be a 'responsible person' for each health organisation whose role will be to collect and monitor data on the number, cause and duration of detentions under the MHA broken down by ethnicity and other demographic information. The Secretary of State must ensure that these statistics are published at the end of each year.

Recommendation 9

The 'responsible person' should also oversee workforce training and policies designed to address bias and discrimination in decision making in the operation of the MHA on the basis of protected characteristics, including the implementation of the Patient and Carer Race Equality Framework ( PCREF).

Government response

Taking action to tackle the disparities currently seen in the application of the MHA is a priority for the government's reform agenda. Indeed, concerns around disproportionate use of the MHA is one of the reasons the government first commissioned Sir Simon Wessely to undertake the independent review of the MHA.

The proposals for legislation contained within the draft bill itself reflect the government's aims to improve the experience for everyone subject to the act, including people from ethnic minority groups, who the statistics show are currently subject to disproportionately higher rates of detention. Non-legislative action is already being taken forward to address disparities, including through the department's culturally appropriate advocacy pilots and the roll-out of NHS England's PCREF.

We thank the committee for their consideration of issues relating to inequality and where we might go further, and for their recommendation that a 'responsible person' be introduced across each health organisation. We envisage this being an additional duty on existing senior staff rather than a new role. We will consider the proposal further ahead of introduction of the bill, including how this would align with existing duties - for example, under the Equality Act and the public sector equalities duty.

Recommendations 11 and 16

Recommendation 11

The government should work with NHS England to produce an implementation plan for the NHS's non-legislative programmes to address inequalities in mental health care with clear milestones and reporting against them. Examples of milestones might include appointment of 'responsible people', take up and implementation of the PCREF, increased awareness of the public sector equality duty, reductions in disproportionate detention rates, improved diversity in the workforce and access to culturally appropriate advocacy, which is discussed later in this report.

Recommendation 16

The government should publish a comprehensive implementation and workforce plan alongside the bill. It should contain clear actions and key milestones detailing the implementation of the bill and how they link to milestones in the implementation of the 10 year plan and other relevant government policies. These should include milestones on workforce development, training, advocacy and community care capacity, as well as on numbers of detentions, length of stay and reducing racial and ethnic inequality. There should be a statutory duty to report annually to Parliament on the progress against these milestones during the implementation period.

Government response

We thank the committee for their recommendations in relation to the publication of implementation plans, and for the accompanying suggestions for what these might include. We agree that the effective implementation of the planned legislative changes and accompanying non-legislative programmes will be critical in delivering the government's MHA reform ambitions.

To this end, we will set out how we intend to deliver these reforms, both legislative and non-legislative, alongside the bill when it enters Parliament. We intend for this plan to include information in relation to the planned sequencing of the commencement of provisions, and also cover where possible actions to support necessary workforce development and to address disparities. We will work closely with our partners, including NHS England and other arm's length bodies, to ensure these plans are deliverable and align with the NHS Long Term Workforce plan published in June 2023, which identified the need to grow the overall mental health and learning disability workforce the fastest of all care settings, at 4.4% per year up to 2036 to 2037. We will also keep stakeholders informed on progress during the implementation period and keep the implementation of the provisions included in the draft bill under review.

A number of non-legislative plans are already being taken forward - for example, the department's commissioning culturally appropriate advocacy pilots and NHS England's work to implement the Advancing Mental Health Equalities strategy. As part of the latter, NHS England intends to launch PCREF across all NHS mental health trusts later this year. NHS England is also launching a quality improvement programme in NHS mental health trusts across the country, which will improve the quality of care and experience for patients subject to the MHA.

Recommendations 12, 13 and 14

Recommendation 12

The evidence shows that community treatment orders ( CTOs) are being used more than intended and, in many cases, as a more restrictive alternative to discharge. There is not enough evidence to demonstrate benefit for the use of CTOs for part II patients to justify their continued use, especially as they are used disproportionately for black and ethnic minority patients. We recommend that CTOs are abolished for patients under part II of the MHA.

Recommendation 13

We have received some evidence that suggests unrestricted part III patients may benefit from CTOs. However, that evidence is inconclusive, so we recommend that the government should amend the draft bill to include a statutory review of CTOs for part III patients, to report within 3 years of Royal Assent.

Recommendation 14

We also recommend that the bill contains a provision that abolishes CTOs for part III patients 6 months after the time for the statutory review recommended above expires (or earlier with the approval of both Houses of Parliament). This would give the government time to introduce legislation to stop the abolition of CTOs for part III patients if the statutory review demonstrated convincingly that they had value and were now being used in a non-discriminatory way. If that were not the case, they would be abolished automatically without need for further legislation.

Government response

Although we recognise that this proposal would receive some support, this is a complex matter that was considered in some depth by Sir Simon Wessely's independent review of the act. We believe that it is right that we continue to reform CTOs as the independent review recommended and for which the draft bill now provides.

The reforms we have set out in the draft Mental Health Bill seek to address the committee's concerns regarding longstanding issues, notably people being on a CTO for far too long, when it is no longer appropriate, and especially, black people being disproportionately made subject to CTOs.

Under the government's proposals, we will reform CTOs so that they can only be used where there is a strong justification and a genuine therapeutic benefit for the patient. Such patients include those with complex symptoms (for example, psychosis) and comorbidities or other risk factors (such as homelessness) who have insufficient insight into their illness so would be at risk of disengaging once in the community. These patients often require time and supervision to achieve stability of their symptoms which then allows them to engage with treatment on a voluntary basis. We will also introduce greater scrutiny of their use through the involvement of community clinicians in arrangements for care after discharge from hospital, and by providing greater oversight by the mental health tribunal. These measures should help to guard against CTOs being disproportionately used for black patients.

The government continues to uphold the principle that the community may be the most appropriate place for treatment for some patients under the act. Our approach is focused on how best to treat a patient and, where that might include community treatment, we do not consider that the availability of such treatment should depend on whether a person is subject to part II or to part III of the act.

For some patients, CTOs provide the least restrictive option that ensures patients receive the ongoing support they need - but in the community, rather than having to stay in hospital. It is important that we strike the right balance between the risks and benefits to patients, as well as considering any potential unintended consequences related to the abolition of CTOs. The government is concerned that one such risk would be an increase in delayed discharges if there is no appropriate framework to allow for discharge into the community for patients felt to be high risk. There is also a risk of a consequential over reliance on other areas of the act that are not designed for longer term cases such as continued detention and placement on leave of absence under section 17 of the MHA.

Recommendation 15

We recommend that the introduction of the final bill should be accompanied by a revised impact assessment to take account of changes in the workforce and the economy since the original was published. It should also be explicit about the extent of interdependencies with other government programmes and policies.

Government response

The government agrees that an updated impact assessment should accompany the final bill. The final impact assessment will reflect changes to the proposals, workforce and economic indicators where relevant. The impact assessment will also consider interactions with non-legislative measures and existing programmes that fall within the scope of the reforms. We will continue to work with NHS England and CQC when developing the impact assessment.

Recommendation 17

We were disturbed by the evidence we received that the concept of 'capacity' has been misused to deny treatment to very ill and potentially suicidal patients when they have voluntarily sought it. We recommend that the government set out in the response to this report what it, the CQC and NHS trusts are doing and will do to prevent this practice.

Government response

The government agrees that denying treatment to patients in these circumstances not only goes against the spirit of both the MHA and the Mental Capacity Act ( MCA) but may also fall short of professional standards. The government will consider amendments to the code to make guidance on this point clearer. We will also work with professional bodies to investigate whether we can improve the way that clinicians communicate and engage with patients about capacity and suicide. We note the committee's findings that this issue often occurs in relation to people with complex emotional needs and/or a diagnosis of 'personality disorder' or eating disorders. Ongoing work set out in the NHS Long Term Plan will also help improve the pathways for these patient groups and improve training for clinicians. CQC continues to monitor services to ensure they implement effective safeguards for all cohorts of patients.

Recommendation 18

We welcome the government's confirmation that there will be further guidance on applying the new detention criteria in the code of practice. We recommend that this particularly address the definition of 'serious' harm and give guidance on how the 'likelihood' of harm should be assessed. This should balance the need to ensure detention is a last resort with the potentially greater therapeutic benefits of an earlier intervention in some cases. It should be clear that the change in criteria should not be used to deny care to those who need it and would benefit from it, including where serious harm would arise from a breakdown in personal circumstances, health neglect or deterioration.

Government response

The government agrees that it will be important to clarify the new detention criteria in the code of practice. This has always been our intention and we will take the committee's recommendations into account. We will set out in guidance our clear view on how the terms 'serious harm' and 'likelihood' should be interpreted in practice by decision makers.

Recommendation 19

We recommend that the consideration of 'how soon' harm might occur should not be included in the draft bill itself. This was not in the independent review's recommendation and would be better handled in the code of practice. While we recognise what the government is trying to achieve, it will be difficult for professionals to assess objectively. We are concerned that it might dissuade potentially beneficial and shorter interventions at an earlier stage that would be in keeping with the principles. We recognise that some witnesses saw this provision as tackling the very real issue of long-term detentions of questionable benefit, but believe that these are already, and more effectively, addressed under other provisions in the draft bill, such as increased reviews by tribunal.

Government response

The government will review the wording on 'how soon' harm may occur. We included this wording in response to the independent review's finding that detentions currently could be justified by concerns about harms that may only occur far in the future. There is no express requirement in the current detention criteria for clinicians to consider the time element of when harms will occur, and we sought to clarify this. We note the committee's concerns about the potential unintended consequences of this wording and will work to see how best to address this matter.

Recommendation 20

We recommend that the code of practice also give guidance on how the definition of 'appropriate treatment' should be interpreted in cases with a relatively low chance of improvement, or where resourcing means treatment may not be immediately available. It should also make clear that 'appropriate treatment' includes non-drug-based treatment.

Government response

The government agrees that it will be important to explain, including in relation to the new detention criteria, what is meant by 'appropriate medical treatment' in the code of practice. The government agrees, as we stated in the white paper, that therapeutic benefit is about more than just medication. We will set out in guidance our clear view on how the term 'appropriate medical treatment' should be interpreted in practice by decision makers.

Recommendation 21

At present the changes in the draft bill mean it may be easier to be detained under part III of the MHA, which deals with those who are in the criminal justice system, compared to part II, which covers the rest of the population. We have heard convincing evidence that this is difficult to justify on the grounds of risk and that it could result in an increase in black people, autistic people and people with learning disabilities being detained under part III of the act. This would be contrary to the aims of the review and the draft bill. We recommend that the changes in detention criteria should be consistent for individuals under either part II or part III of the MHA.

Government response

The government acknowledges the committee's concerns over the potential consequences of our proposed reforms. However, leaving the detention criteria for part III patients as currently drafted will ensure that, for example, vulnerable neurodivergent offenders in the criminal justice system, who would otherwise go to prison, can continue to be diverted to hospital (where appropriate), where they are more likely to receive more therapeutic and specialist support. This view was informed by an expert group of clinicians, third sector organisations and justice stakeholders.

Under the revised act, there will need to be consideration of the therapeutic benefit of all detentions of part III patients, as with civil patients. Where the proposed reforms to the detention criteria differ is the determination of the risk of 'serious harm'. For part III patients this has always been a matter for the courts or the Secretary of State for Justice, taking into account all relevant factors, and it would be inappropriate to rely on the new standard statutory risk test used for part II patients.

Recommendation 22

We recommend that the government conducts a review of the Building the Right Support action plan in light of the proposals in the draft bill. It should identify which milestones in this plan must be met to ensure that people with learning disabilities and autistic people who would have been eligible for detention under section 3 can be supported to live in the community. This review process should include all relevant parties, including service providers and service users. The milestones outlined in this review must then be met before commencement of those parts of the bill that remove learning disabilities and autism as a condition for which people can be detained under section 3.

Government response

We agree with the committee that there will need to be an appropriate level and range of community support available before commencing those parts of the bill which will remove the power to detain people with a learning disability and autistic people without a co-occurring mental health condition under section 3.

We will set out how we intend to deliver these reforms, both legislative and non-legislative, alongside the draft bill as it enters Parliament. This will include detail and milestones in relation to the planned sequencing of the commencement of provisions, including those relating to learning disabilities and autism. The Building the Right Support action plan will be an important source of evidence to help inform this work, as will insights from people with experience of using mental health services and providers.

Recommendation 23

The government monitors outcomes for people with learning disabilities and autistic people who are no longer eligible for detention under section 3. This monitoring should specifically focus on people detained under the MCA or in the criminal justice system, including people detained in long term segregation. The government should commit to act if detention by these routes rises.

Government response

The government agrees that we need to monitor the outcomes of the proposed changes to the detention criteria in the MHA for people with a learning disability and autistic people. We remain committed to reducing the number of people with a learning disability and autistic people detained in hospital. We already collect some data in the assuring transformation data set on detentions of people with a learning disability and autistic people in mental health hospitals under different legal arrangements.

The Department of Health and Social Care is seeking to commission evaluation research of the reforms we plan to commence first and will consider how to monitor whether the full set of reforms are being implemented as planned and early signs of their impact, including for those with a learning disability and autistic people.

Under our proposed reforms, integrated care boards ( ICBs) will be required to establish and maintain a register of people with a learning disability and autistic people at risk of detention under the act. These registers may contain information about detention under different powers of detention and could be a useful tool for monitoring outcomes.

Recommendation 24

We recommend there should be provision by which detention can be continued after the 28 days allowed under section 2 of the MHA for people with learning disabilities or autistic people in tightly defined exceptional circumstances. This should only be available if pre-authorised by a specialist tribunal comprising individuals with an understanding of learning disabilities or autism. The time period should be determined in the tribunal and subject to regular review by the same tribunal. The conditions which constitute 'exceptional circumstances' should be defined in the code of practice; we envisage they might include particularly complex presentations where further assessment beyond 28 days is needed.

Government response

We agree with the committee that it is important people with a learning disability and autistic people can be properly assessed within the 28-day detention period under section 2 to ensure the right decision is made to either continue detention by placing the patient under section 3, where there is a co-occurring mental disorder, or to discharge the patient, where there is not. We recognise that in order to achieve this, assessments must be carried out in a timely manner.

However, we are concerned that this recommendation could lead to unintended consequences. As the committee has identified in its report, treatment in inpatient settings for people with a learning disability and autistic people can be distressing, leading to worse outcomes for a patient and, potentially, perpetuated detention. Given that we are attempting to address the issue of lengthy detentions through our reforms we are not in favour of creating a mechanism by which section 2 detention can be extended beyond 28 days. We are concerned that this would risk creating an alternative route to longer term detention which we know is often inappropriate for people with a learning disability and autistic people.

We will instead focus on a range of non-legislative measures to ensure that individuals can have their needs assessed and be given the right support in a timely manner, such as improved training for clinicians. In addition, the appropriate use of risk registers and improved community support should result in individuals' needs being properly understood before they are detained, should this be considered necessary, thus reducing the need for lengthy assessment processes.

Recommendation 26a

The government should follow through with existing plans to provide enhanced diagnosis, care and treatment for people with learning disabilities and autistic people in prisons.

Government response

We agree with the committee that the prison environment should be as supportive as possible for autistic people and people with a learning disability. As set out in our cross-government neurodiversity action plan which was published in July 2022, the Ministry of Justice and our wider health and justice partners are committed to improving early identification of need and support for neurodivergent people in prison. This includes:

championing autism accreditation across the prison estate

rolling out neurodiversity support mangers in every prison in the adult estate by 2024

piloting digital interventions to support neurodivergent prison leavers

Significant progress continues to be made against all of the commitments made in the action plan as demonstrated by our 6 month and 12 month updates, which were published in January 2023 and September 2023 respectively.

To improve access to healthcare, NHS England's health and justice team is undertaking a number of actions to improve the experience of accessing healthcare for neurodivergent people in the criminal justice system. These actions include developing a network of learning disability and autism prison healthcare champions and developing neurodiversity pathways and guidance materials for the services it commissions.

Recommendation 26b

If the government continues with the provisions as they are in the draft bill, with learning disabilities or autism removed as grounds for detention under part II but not part III of the MHA, it will be imperative that the government develops safeguards to prevent further inappropriate use of part III for this group.

Government response

We are committed to improving the support available, and reducing the need for mental health inpatient care, for all people with a learning disability and autistic people, including those who may come into contact with the criminal justice system. By making the appropriate support available to individuals, we intend to prevent their needs escalating to a point where they may come into contact with the criminal justice system.

NHS England will provide national funding to local systems in 2023 to 2024 for investment in community infrastructure, which is in line with the Building the Right Support service model, including community forensic teams for people with a learning disability and autistic people.

The draft bill will help ensure that commissioners understand the risk of crisis at an individual level in their local area, through introducing a duty to establish risk registers, and ensure an adequate supply of community services for those at risk of admission under part II of the act. These duties will help people avoid reaching a crisis point which could lead to them coming into contact with the criminal justice system.

We will consider whether additional non-legislative safeguards are required to prevent people being detained inappropriately under part III of the act.

Recommendation 27

The government should strengthen the wording of the duty for integrated care boards and local authorities, which currently only requires that they 'have regard to' recommendations in the care (education) and treatment review reports, to ensure that the outcome of each review is actioned effectively. This could be done either by requiring that integrated care boards and local authorities must 'follow' recommendations in the reports or by placing an additional requirement that the integrated care boards and local authority must provide a 'good reason' for not following recommendations in the reports. For example, that the recommendations are not in the best interests of the individual.

Government response

The government welcomes the committee's recommendation and agrees it is important that recommendations from care (education) and treatment reviews ( C(E)TRs) for people with a learning disability and autistic people are followed unless there is a good reason not to.

The 'have regard to' duty is a common duty that clinicians and ICBs, like other public bodies, are used to applying. Indeed, it is a duty that already exists in the act. Further, a duty framed in these terms requires serious consideration to be given to the recommendations made. Such recommendations would ordinarily be followed except where there are clear, cogent and convincing reasons not to do so.

Recommendation 28

The maximum time period between care (education) and treatment reviews is too long, especially when recognising the detrimental effects that inpatient environments can have on people with learning disabilities and autistic people, particularly those who are under 18. The maximum time period between reviews should be shortened from 12 to 6 months.

Government response

C(E)TRs are important in helping to ensure that when people with a learning disability and autistic people are detained under the act their individual needs are identified and met, and steps are taken to support them towards discharge. That is why we are placing them on a statutory footing under our proposed reforms. We agree with the committee that some people with a learning disability and autistic people, particularly those under 18, should receive C(E)TRs more frequently than every 12 months, as set out in current NHS England policy.

The 12-month interval set out in the draft bill is intended to be a maximum time limit between reviews, based on the maximum C(E)TR interval in current NHS England policy. This does not preclude C(E)TRs from happening more frequently than this. Section 125F sets out that the Secretary of State must publish statutory guidance on C(E)TRs, and we would use this to specify when C(E)TRs should happen at shorter intervals than 12 months, in line with current NHS England policy. We designed this approach in the bill in order to allow different C(E)TR frequencies to be set for different circumstances. However, we do recognise there is a risk that C(E)TRs will be carried out to the maximum timings set out in the legislation (12 months), as opposed to those specified in guidance.

We therefore welcome the committee's recommendation to reduce the time between C(E)TRs in the bill and are considering the best way of ensuring that individuals receive C(E)TRs at the appropriate intervals. This could include, for example, ensuring that responsible commissioners have the capability to meet any new legislative requirement for more frequent C(E)TRs.

Recommendation 29a

We recommend that the 'risk register' is renamed 'dynamic support register' in the draft bill to better reflect its purpose.

Government response

We thank the committee for their drafting suggestion and will consider this further.

Recommendation 29b

The government should also consult with people with learning disabilities and autistic people to see how they can build trust in this dynamic support register mechanism.

Government response

We welcome the committee's recommendation and will consider the views of people with a learning disability and autistic people when developing statutory guidance on risk registers, to help ensure ICBs are using registers in a way that individuals feel able to trust.

NHS England has already undertaken work to build trust in risk registers. It has recently published guidance on dynamic support registers ( DSRs) which it co-produced with people with a learning disability, autistic people and their families. This guidance sets out the expectation that local areas will make information about DSRs available, to support people and their families to find out more about the process.

Recommendation 30

We recommend that the government should strengthen the duties on integrated care boards and local authorities to impose a firm duty to ensure the adequate supply of community services for people with learning disabilities and autistic people, using information gathered from the dynamic support register.

Government response

We believe that the provisions contained within the draft bill will be sufficient to ensure adequate supply of community services, and we agree with the committee that this support will be vital. Under the proposed section 125E, both ICBs and local authorities will be required to have regard to information made available through the risk registers and commissioners will be under a duty to seek to ensure that the needs of people with a learning disability and autistic people are met in the community, so that they may avoid detention under part II of the act.

Recommendation 31

The duty on integrated care boards to 'establish and maintain' a register should be strengthened to include more proactive language, for example, using the 'develop and maintain' duty in existing NHS policy for dynamic registers. We also recommend that the factors to be set out by the Secretary of State to indicate that an individual is at risk of admission have sufficient clarity to avoid the misinterpretation of risky behaviour as risk of admission, and to give clarity to individuals on the register and their families.

Government response

We agree that it is important that ICBs are proactive in identifying people with a learning disability and autistic people to be included on a risk register and will consider whether this drafting suggestion helps to achieve this.

We agree with the committee's recommendation that risk of admission factors need to be clear and will seek to achieve this when drafting the regulations setting these out. We intend that this will provide clarity for individuals and their families and will support health and social care professionals to correctly identify individuals who should be on the register. This will also help to ensure that sufficient services are commissioned locally and provide an additional tool for understanding the person's needs to help prevent them reaching a crisis point.

Recommendation 32

Section 117 aftercare, proportionate to need, should also be extended to patients who are admitted under the 'exceptional circumstances' route recommended above (recommendation 24).

Government response

We recognise the importance of people with a learning disability and autistic people being properly supported in the community upon discharge. However, as we are addressing the concerns which led to recommendation 24 through non-legislative means, rather than introducing a mechanism for extending section 2 detention under 'exceptional circumstances', this recommendation will not be taken forward.

We are introducing measures in the bill, through new duties on commissioners, that will help to ensure people with a learning disability and autistic people who are discharged from an inpatient setting receive the right support in the community to meet their individual needs.

Recommendation 33

The government should commission research into the likely costs and benefits of extending aftercare, proportionate to need, to patients who are detained in mental health settings under provisions other than section 3 of the MHA, including those admitted for more than 28 days or detained under the liberty protection safeguards of the MCA. Informed by this research, the government should consider extending section 117 aftercare, or an equivalent aftercare provision, where appropriate.

Government response

Aftercare under section 117 of the MHA is already available to people who have been detained under sections other than section 3 - sections 37, 45A, 47 and 48 of the act are all qualifying sections for people who then cease to be detained and leave hospital. Although we appreciate there is a demand for entitlement to be extended, it is the government's view that the existing position generally serves to ensure that it is those patients who have the greatest need who benefit from the support.

Recommendation 34

The government should consult on the introduction of a statutory test for competency, or 'child capacity', for children under 16. This consultation should be wide ranging and consider the wider implications of this reform on other areas of law affecting children.

Government response

The government appreciates that there are different opinions about matters to do with children and young people's rights, and on the best approach to assess their capacity and competence. But these considerations are relevant to people in all settings, not just to those detained under the MHA. The MHA is not the appropriate forum for setting a statutory test for child competence in wider settings. Gillick competence remains the accepted competence test for under 16s across all settings.

We have heard that some stakeholders would like a statutory test for competence for under 16s in the act. The government is concerned, however, that setting out a statutory test for competence in the MHA could potentially put under 16s in a more complicated position, particularly those assessed as having competence to consent to decisions under the MHA definition but who would be considered not to have competence using the existing test of Gillick of competence, or vice versa. We think that the best place to set out how practitioners should assess children and young people's competence and capacity under the act is in the code of practice, and we will consult with stakeholders when we come to review this.

Recommendation 35

The government must take the opportunity of this legislation to strengthen the protections in the MHA against children and young people being placed in inappropriate settings, such as adult wards or placements out of area. For example, the draft bill must amend duties on hospital managers to ensure that there are sufficient services for children and young people, and there must be stronger procedural requirements where inappropriate placements are considered, including that such a placement is demonstrably in the child's best interests. It is imperative that these reforms coincide with developments in the provision of specialist services for children and young people to address the core driver of this problem.

Government response

The government agrees that children and young people should not be placed in inappropriate settings and will explore what more can be done, outside of legislative changes, to reduce the instances where this occurs.

Section 131A of the act already places a duty on hospital managers to ensure that the patient's environment in the hospital is suitable having regard to their age, while section 140 requires ICBs to inform local authorities when accommodation suitable for children becomes available. NHS England's regional specialised commissioning teams are delivering an accelerated bed programme which aims to improve patient outcomes and experience by eliminating inappropriate out of area placements, improving local bed availability aligned with community services, and eliminating inappropriate under 18 placements in adult beds.

In 2021 to 2022, we provided an additional £79 million to expand children's mental health services which allowed around 22,500 more children and young people to access community health services. We are also investing £150 million of capital funding in NHS urgent and emergency mental health infrastructure to support people to receive care in more appropriate settings outside of A&E. This includes settings that will specifically support children and young people.

Recommendation 36

We recommend that there should be a statutory right for patients who have been detained under the MHA to request an advance choice document be drawn up. These should also be offered to everyone who has previously been detained, as recommended by the independent review. This provision should extend to people with learning disabilities or autistic people who have been detained under the MHA, including section 2, section 3 prior to the commencement of the changes in the draft bill, and the 'exceptional circumstances' route outlined in paragraph 180 of the committee's report. They should be recorded in a way that is accessible digitally, linked to a patients' GP records, and usable quickly in crisis settings, including by first responders such as the police and paramedics.

Government response

We agree that a mechanism to store ACD information digitally is the best means of ensuring that they can be shared easily and readily accessed by the relevant professionals at the point of need. We continue to explore how best to achieve this in a way that supports take up and accessibility, in both the short and longer term, alongside NHS England and external stakeholders.

Recommendation 37

We heard evidence that when the patient is meaningfully involved in the creation of their ACD this helps build trust. Therefore, we recommend that to facilitate such involvement this should be done with the support of a trained person who is independent of the service users' treatment team.

Government response

We agree that the person should be at the centre of their ACD and therefore it is critical that they are meaningfully involved in its creation. To facilitate this, we agree that the support of a person who is independent of the individual's treatment team can be important, whether for instance that be a loved one, a peer support worker or a clinician. However, we think that the person should also be able to rely on the input of their treatment team, who will be well positioned to advise on what options might be available to the individual should they be detained under the act. Ultimately, we want to uphold the principle of patient choice and autonomy in this respect.

We are aware of various research studies that have explored this issue, and we are working closely with stakeholders to develop a model that works best.

Recommendation 38

We agree with the independent review that a slimmed down mental health tribunal should be able to consider whether a patient is entitled to challenge their treatment plans, if requested, following a second opinion appointed doctor (SOAD) review of their care and treatment plan or a major change in treatment. We recommend that the government amend the draft bill to allow for pilots in the first instance, to ensure that the additional workload is manageable and the tribunal and clinicians' roles are not compromised.

Government response

We appreciate the committee's thorough consideration of this policy proposal. However, we do not consider that it would be appropriate for the tribunal to be able to review each and every aspect of a patient's treatment. In particular, we do not think the tribunal should be able to make determinations about whether an individual clinical judgement about treatment, made in good faith, is right or wrong in a particular case. Therefore, we do not see a rationale for taking forward the pilots proposed by the committee.

We also continue to be of the view that the new measures included in the draft bill already significantly improve the autonomy that patients have over their care and treatment. For example, those around advance decision making, the 'clinical checklist' and the new, stricter rules around when refusal of medication by a person with capacity can be overridden.

We agree, however, that the patient's care and treatment should play a more central role in the tribunal's consideration of whether their detention should continue to be upheld or not. We intend to achieve this through our proposed changes to the detention criteria, which place a greater emphasis on the principle of therapeutic benefit, and by working with HM Courts and Tribunals Service and the judiciary to agree how the patient's statutory care and treatment plan can be used in tribunal proceedings to help inform decision making.

Recommendation 39

The nominated persons provisions for adults are welcome, necessary and reflect the principle set out in the independent review to support patient choice and autonomy. We recommend that the government work with approved mental health professionals ( AMHPs) to revise the proposals to address the practical concerns that have been raised with us and ensure the benefits of these reforms as envisaged by the independent review materialise.

Government response

We appreciate that there are concerns that some aspects of the current process for appointing a nominated person on behalf of the patient may be challenging for AMHPs. We accept the recommendation to work with AMHPs to improve the practicalities around appointing a nominated person in the legislation.

The nominated person provisions provide patients with choice and the opportunity to exercise autonomy. It is important that the uptake of nominated persons is supported by a nomination process which is both robust enough to ensure that nominations are not subject to doubt while avoiding being overly complicated or inflexible for health and social care professionals. We have been working with AMHPs and intend to amend the bill in order to improve the final provisions which allows us to maintain our policy objectives without being overly burdensome on staff.

Recommendation 41

The government should consult specifically on how nominated person provisions will apply to under 18s in regard to potential conflicts with other legislation affecting children, such as the Children Act 1989. It should come forward with new proposals on how the nominated person provisions will apply to under 18s at an early stage in the bill's progress.

Government response

We appreciate stakeholders are keen to ensure that the interface between the bill and existing legislation concerning children is clear. We will work closely with stakeholders to ensure that any potential points of confusion are addressed, and that children and young people are appropriately safeguarded. In terms of the right to appoint an NP with respect to under 18 year olds, we aim to take forward the provisions already included in the draft bill which will allow young people aged 16 or 17 the same right to choose an NP as an adult, and allow under 16s this choice as long as they are Gillick competent. We originally proposed this in the white paper and consulted on whether under 16s in particular should have this right and the majority of respondents agreed with our proposal. We will continue to work with stakeholders to ensure that the appropriate safeguards are in place to enable greater autonomy for children and young people.

If the child does not nominate their parent, the parent will maintain all their existing legal rights, including to be consulted on certain decisions and to receive information about the child's care and treatment (subject to the child's confidentiality rights and safeguarding concerns). In our view, the child should be informed that the parent maintains these rights and we will make this clear in the code of practice. Similarly, where a child is under a care order and parental responsibility sits with the local authority, the local authority will retain their parental responsibilities to the child even if the child chooses an NP who is not the local authority. We intend to clearly describe the respective roles and decision making powers of the NP and the body or person with parental responsibility in the code of practice.

Recommendation 42

We welcome the 'opt-out' advocacy scheme for detained patients. Once capacity has been built up in the advocacy sector, as measured against the annual independent mental health advocate ( IMHA) workforce modelling targets in the impact assessment, it should be extended to include informal (voluntary) patients as well. This would bring particular benefits to children and young people, most of whom are informal patients. The bill should include the powers to do this, to be commenced only once capacity exists to support informal patients on top of those who have been detained.

Government response

We recognise the important role the IMHA service can play in supporting informal (voluntary) patients, particularly children and young people. That is why we are seeking to extend the right to an IMHA to informal patients in the draft Mental Health Bill. We have prioritised the 'opt out' scheme for formal patients, who are subject to greater restrictions and are potentially more vulnerable compared to informal patients.

Although the opt out scheme will not apply to informal patients, the draft bill places a duty on hospital managers to make informal patients aware of their right to an IMHA, so that they can access the support and advice available through the advocacy service.

Our reforms aim to offer a greater level of support and representation to all patients, including children and young people.

Recommendation 43

There are shortages of advocates with the specialist knowledge of learning disabilities and autism, relevant language skills or cultural knowledge to support patients with specific needs. The government should examine the case for a central advocacy service, to meet the needs of specific groups who may otherwise go unsupported in some areas.

Government response

We agree that it is important that advocacy services appropriately support people with specific needs and people from different groups. We have taken forward discussions with delivery partners regarding the introduction of a centralised advocacy service, including to consider potential policy and implementation requirements, and are minded not to pursue such a model at this stage. We think there is a particular value associated with the commissioning of advocacy at a local level, where independent advocates know and are able to effectively navigate local systems with their clients. We also expect all advocacy services to make reasonable adjustments to meet the varying needs of the people they are representing and supporting, including as required under the public sector equality duty. The creation of a national service would risk creating confusion and potential gaps, including in relation to differing respective roles of local and any nationally commissioned service provision. Our preferred approach is therefore to work with the advocacy sector to improve and upskill existing provision, including through staff training, to ensure that all local services are able to meet specific needs.

Recommendation 44

The bill should include a statutory right to request culturally appropriate advocacy, as defined in the existing pilots. The government should consider the workforce requirements needed for this change and the impact assessment and implementation plan should ensure adequate timing to develop services. The second round of pilots should be evaluated before commencing this right so that lessons can be learnt in its implementation.

Government response

Culturally appropriate advocacy has the potential to play a significant role in helping address the racial disparities currently seen in the application of the MHA.

We are not in favour of introducing a statutory right to access such services in the legislation at this stage, however. Rather, we intend to consider the findings from the pilots before deciding if legislation would be the correct mechanism for implementation of such a policy and, if so, what any statutory right could look like. This will allow us to further build our understanding of what such services might entail, how they may be delivered, and the improvements in outcomes that they might support. When commissioning advocacy services, local authorities are already required under section 149 of the Equality Act 2010 to eliminate discrimination and advance equality of opportunity, including in respect of taking steps to meet specific needs based on race as well as religion or belief and other protected characteristics.

Recommendation 45

We recommend that there be a statutory duty to collect and publish data on the use of supervised discharges, including duration, cause and demographic profile. We recommend that there be a statutory review after 3 years from the commencement of this clause and that the provision will expire following that review, unless renewed through approval of both Houses of Parliament.

Government response

The government agrees there should be transparency and scrutiny over the use of supervised discharge, but we intend to take this forward through non-statutory means.

Data on conditional discharge, including demographic data, is already published through the annual restricted patient's statistical bulletin and the use of supervised discharge will be included in this. While all the information recommended by the committee will be collected, it may not always be possible to publish demographic data if patient numbers are low as this could lead to individuals becoming identifiable. It would also be inappropriate to publish the reasons an individual requires deprivation of liberty conditions for the same reason.

As recognised by the independent review, these provisions are necessary to fill a legal gap preventing patients from continuing their care in a less restrictive setting. The government will work with stakeholders to closely monitor the impact of these reforms to ensure the powers are being used proportionately and appropriately and in line with the policy intent.

Recommendation 46

Despite the government's preference for consistency with the approach for other forms of conditional discharge, we consider that extra safeguards are necessary given that this form of discharge involves the deprivation of liberty. We recommend that the tribunal must be involved in the decision to place someone on a supervised discharge, as recommended by the independent review, to ensure that therapeutic benefit is being considered in this process.

Government response

The government agrees that therapeutic benefit should be considered in supervised discharge decisions, but this can be achieved without compromising the Justice Secretary's public protection duties in respect of these patients.

Restriction orders are given by the independent judiciary to ensure the Secretary of State for Justice has oversight of dangerous patients. It would be inconsistent for the tribunal to have more powers than the Secretary of State for Justice over supervised discharge, given these patients will present a higher public protection risk than those suitable for ordinary conditional discharge.

The Secretary of State for Justice applies a slightly different test to that of the tribunal in order to preserve their discretion in the interests of public protection, but conditions for patients must still be appropriate and proportionate. We will publish operational guidance to make clear that the Secretary of State for Justice should have regard to the principle of therapeutic benefit and only use this type of discharge when the evidence indicates it is in the best interests of the patient. Explicit safeguards are present in the draft bill, providing these patients with regular access to the tribunal once a decision has been made to ensure the arrangements remain therapeutically beneficial. We are continuing to work with stakeholders to consider whether further safeguards would be appropriate.

Recommendation 47

The government should consult with the CQC and set out in their response to this report how community care homes or other establishments in which individuals may be residing under supervised discharge can be appropriately regulated and inspected, relative to hospitals, considering the deprivation of liberty patients will be under.

Government response

We agree with the committee that regulatory oversight would provide an enhanced safeguard for individuals subject to supervised discharge, given that these individuals will be deprived of their liberty.

We are consulting with the relevant regulatory authorities in England and Wales to consider expanding their existing powers under the MHA to cover all patients subject to a supervised discharge in the community.

Suitable placements for these patients may be found in care homes in the community or other premises which are equipped to provide the right level of care and support, in order to protect the public while also giving patients greater independence than is available in a hospital setting. We are exploring what level of regulatory powers would be appropriate, given the different nature of these settings relative to hospitals.

Recommendation 48

For the 28-day transfer deadline to be meaningful we recommend that 'seek to' be removed, so that the duty is to ensure that the deadline is met. We appreciate transfers involve multiple authorities and bodies with some lenience being needed, but if included in legislation it should be a meaningful deadline that can be applied to services who should be expected and are supported to meet it.

Government response

The government remains committed to reducing delays for those prisoners who meet the threshold for detention under the MHA to access inpatient treatment. The current wording in the draft Mental Health Bill, to 'seek to ensure' a transfer occurs within 28 days of initial referral, is sufficiently robust to provide accountability for a breach of the time limit, while recognising that multiple agencies are involved in the transfer process. We consider that 'seek to ensure' would likely be construed by courts as parties making every reasonable effort to ensure the timeline is met. We will ensure that the explanatory memorandum published alongside the bill emphasises the statutory duty upon responsible parties to make every reasonable effort to ensure the transfer occurs within 28 days.

Recommendation 49

The government should set out an action plan alongside the bill that has a clear timeline and process for how all services will achieve this deadline.

Government response

As referenced earlier, the effective implementation of the planned legislative changes and the accompanying non-legislative programmes is critical for delivering the government's MHA reform ambitions. To this end, we plan to publish an action plan for how services will achieve the statutory 28-day deadline for transfers from prisons and immigration removal centres to hospital, which will be set out alongside the introduction of these provisions in Parliament.

Recommendation 50

The government should include the newly developed statutory independent role to monitor and manage prison transfers in the bill when it is presented to Parliament, as stated by the minister.

Government response

The government welcomes the committee's assertion that independent oversight of the transfer process would be valuable to protect patients' interests. To ensure flexibility in the design of the role, we believe we can pursue these agreed objectives through a non-statutory role. As stated by Minister Hinds during the Joint Committee's evidence session on 23 November 2022, we are continuing to explore the best way to do this and will share details of this non-statutory role before the bill is presented to Parliament.

Recommendation 51

We recommend that the government should consult further on a short-term emergency detention power, and whether this would provide greater legal clarity to clinicians and accountability for what is happening in A&E services.

Government response

The government recognises that there are pressures in A&E which can prevent people in a mental health crisis from timely access to mental health crisis care. The delivery plan for recovering urgent and emergency care services, published in January 2023, sets out action to increase capacity, grow the workforce, improve discharge, expand and better join up health and care outside hospital, and improve access to the right care.

DHSC, NHS England, Home Office, the National Police Chiefs' Council, the Association of Police and Crime Commissioners, and the College of Policing have recently published a national partnership agreement (NPA) to work together towards reducing inappropriate involvement of police in responding to mental health related incidents, and support individuals experiencing acute mental health distress and in need of medical help to get the right care at the right time.

Alongside the draft bill, we announced £150 million of capital funding for crisis services. This funding will provide additional alternatives to emergency departments, including crisis houses and health-based places of safety, and help people to receive support in more suitable environments. The funding also included £7 million for mental health ambulances, to help reduce pressure on general ambulances and avoid police conveyance of people in mental health crisis.

The government accepts that there may be a need to provide greater legal clarity to clinicians in A&E. We will continue to engage with stakeholders to understand how the current legal framework is being applied and what, if any, legislative changes may be required.

Recommendations 25, 52 and 53

Recommendation 25

The government should urgently review the operation of the MCA in this context with a view to amending the deprivation of liberty safeguards (soon to be liberty protection safeguards) so they cannot be used as an alternative route to the MHA to deprive people with learning disabilities or autistic people of their liberty in inpatient mental health units for lengthy periods of time and thereby undermine the intention of this bill. We reflect that this would be a specific disorder exclusion from the liberty protection safeguards ( LPS), which have not yet been put into practice. We also recommend that the government re-examine the inclusion of other specific disorders under the LPS in this context in future, for example, dementia.

Government response

The government does not believe that it is always inappropriate for the MCA to be used to authorise a deprivation of liberty for the treatment of mental health conditions. In certain circumstances, where a person lacks the relevant capacity but is not objecting to admission to hospital or treatment, it may be the most appropriate option.

We think it is right in these circumstances that clinicians are able to make a choice between using the MCA or the MHA, based on the specific individual needs of the patient. We will work to improve and clarify the interface between the 2 legal frameworks in the code of practice.

The government notes the concern of the committee that deprivation of liberty safeguards ( DoLS) will continue to be available to apply to some people with a learning disability and autistic people when the bill is implemented.

The government's objective is to minimise length of detention and secure the reduction of the number of people with a learning disability and autistic people who are compulsorily admitted to hospital by supporting them to live fulfilling lives in their community. In order to support this ambition, through the bill we are aiming to reduce the scope of the MHA to detain people with a learning disability and autistic people without a co-existing psychiatric illness. This ambition is also reflected in our proposed reforms that help to ensure that commissioners understand the risk of crisis at an individual level, through the duty to establish risk registers, in their local area and ensure an adequate supply of community services.

There may, however, still be cases where a person who has a learning disability and/or is autistic, and who lacks the relevant capacity, needs care and treatment arrangements that require a deprivation of liberty. The government will review the impact of changes to the detention criteria with regard to people with a learning disability and autistic people, with the aim to ensure detention in hospital is only used where there is a direct therapeutic benefit to the person, and not simply a displacement from the MHA to the DoLS.

Recommendation 52

The government should look to resolve the 3 gaps or ambiguities in the law regarding the interface of the MHA and the MCA identified in this subsection, through amendment of the MCA if necessary. Such relatively minor changes could make a significant difference to simplifying decision making in difficult circumstances, without prejudicing the rights of the patients concerned.

Recommendation 53

Our inquiry has highlighted the complexity and unintended consequences of the interface between the MHA and MCA. This issue needs to be addressed. We recommend that the government review the interaction between the 2 pieces of legislation as part of the process of ongoing reform recommended earlier in this report. In particular, it should review the use of the MCA to authorise admission to, and treatment in, mental health units.

Government response

We recognise that the MHA is, at times, being used in cases where it may be preferable to use the DoLS. We note the concerns raised by the committee regarding the complex nature of the interface between the MHA and the MCA and recognise that this may present challenges for decision makers. We will continue to consider the interface between the MHA and the MCA as we implement our mental health reforms. We will also continue to engage with stakeholders to understand what support and guidance could help improve application of the interface.

The 3 specific ambiguities identified by the committee in recommendation 52 relate to the LPS. The government has decided to delay LPS beyond the lifetime of this Parliament, and therefore we will not be considering these specific issues at this point in time.

We will continue to consider the interface between the MHA and the MCA as we implement our mental health reforms. We will also continue to engage with stakeholders to understand what support and guidance could help improve application of the current interface.

Recommendation 54

We recommend that all people known to a mental health service with a known learning disability and/or autism should have the reasonable adjustment flag attached to their record, with an option for individualised adjustments of preferred communication and the name of their advocate.

Government response

The government agrees with the committee's recommendation.

NHS England is working to implement a reasonable adjustments digital flag within patient records to enable health and social care staff to recognise that someone has a learning disability or is autistic, at the point of contact. The flag will also allow health and social care staff to record, share and view details of a person's needs for reasonable adjustments, allowing services to tailor support appropriately. What is recorded on an individual's reasonable adjustments flag will need to take account of their needs and wishes.

Recommendation 55

The provision of appropriate places of safety will be crucial to reducing detentions and reducing the pressures on A&E and police services, especially following the welcome removal of prisons and police custody as places of safety. We recommend that the government increases the provision of appropriate health-based places of safety, and include plans for this within the implementation plan recommended in chapter 2.

Government response

The government agrees with the committee about the importance of health-based places of safety. We continue to invest in additional health-based places of safety, as well as a range of other crisis services, as part of the £150 million capital investment programme for mental health announced by the government in January 2023. This funding will assist with the removal of police stations as a place of safety in all circumstances, as well as building capacity in preventative services so that people do not reach the crisis point in the first place.

Annex A: drafting points

This table contains the government's responses to the points made in Appendix 3 of the Joint Committee's report on aspects of drafting.

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Government response to the Joint Committee on the draft Mental Health Bill

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Presented to Parliament by the Secretary of State for Health and Social Care by Command of His Majesty. March 2024 CP 1036 ISBN: 978-1-5286-4428-0 The Mental Health Act 1983 governs the compulsory detention and medical treatment of people with severe mental illness, people with a learning disability and autistic people for their own safety or for the protection of others.

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(To see JD document- right click on space above, download attachment and click continue if needed).

Agreement for Associate Director of Social Work post.

Dear colleagues. I’m very pleased to share that Diane Hull has confirmed that we’ve had agreement for a Associate Director of Social Work to be appointed to provide professional leadership Trustwide. This will be a 0.5WTE band 8d post and the hope is it will be out to advert in July.

Diane is making some final changes to the job description but this will be a strategic role reporting to her, with a direct line into the Trust Board. Thanks to all of you who have contributed your time and thoughts into what this role could look like- once I hear more I’ll make sure it’s circulated but please find attached the draft JD for people to have a look in the meantime.

Thanks, Kelly Kaiser

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DRAFT Notts HC AD of social work job description May 2024

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The Right to Remain Toolkit- Immigration and Right to Remain guidance (asylum/ immigration/ visas)

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The Right to Remain Toolkit- Immigration and Right to Remain guidance (asylum/ immigration/ visas)

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Human rights: family and private life (Article 8)

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You may be able to apply for the right to remain in the UK based on a human rights argument: your right to family and/or private life in the UK. This is sometimes called an ‘Article 8’ application.

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Set up in 2016, the D2N2 Teaching Partnership's social work academy for excellence is made up of ten local partners from the social work sector and has been funded, by the Department for Education and Department of Health, to improve and enhance the quality of social work training in the region, as well as providing a research-led and practice-based CPD programme to existing social workers across the region.

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Welcome to the D2N2 Teaching Partnership

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Set up in 2016, the D2N2 Teaching Partnership's social work academy for excellence is made up of ten local partners from the social work sector and has been funded, by the Department for Education and Department of Health, to improve and enhance the quality of social work training in the region, as well as providing a research-led and practice-based CPD programme to existing social workers across the region.

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Another World Mental Health Day has begun. This annual opportunity to prioritise our psychological wellbeing feels more essential than ever in uncertain times.

Read more

I was delighted when the National Institute for Health and Care Excellence began work on guidelines for social work with adults experiencing complex needs. I am pleased to host blogs from two members of the guideline committee, Ellie and Chloe, who reflect on their involvement and the guidelines' importance.

NICE (the National Institute for Health and Care Excellence) have guidelines for social work with adults experiencing complex needs. This is the second of two blogs from members of the guideline committee, Ellie and Chloe, who reflect on their involvement and the importance of the guidelines.

Earlier this summer , the Department of Health and Social Care's plan for digital health and social care included the assertion that the "long-term sustainability of health and social care is dependent on having the right digital foundations in place, and so digital transformation must be the linchpin upon which all... reforms are based."

With so many recent challenges and experiences in the pandemic, Jason Brandon, Mental Health Social Work Lead at DHSC, can't think of a more suitable title to this blog post, which describes the dignity and professionalism of the approved mental health professional (AMHP) workforce. It's National AMHP Day!

I am delighted to have a guest blog from my social work colleagues in Bradford and people with whom they work. Together they have made great progress in making sure people with learning disabilities achieve citizenship inclusion outcomes in many ways, but very importantly, through exercising their right to vote.

It is with a sense of relief, but also pride in our collective resilience as a profession, that we are able to publish the Chief Social Worker for Adults Annual Report 2021-22 in a world which has, at long last, regained some of the familiar trappings of normality.

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Another World Mental Health Day has begun. This annual opportunity to prioritise our psychological wellbeing feels more essential than ever in uncertain times. Read more I was delighted when the National Institute for Health and Care Excellence began work on guidelines for social work with adults experiencing complex needs.

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From October this year, the 'Social Worker' blog will be changing its name to 'Children's Social Care and Support' blog. The blog will be for all those working across children's social care and support, in such areas as social work, ...

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From October this year, the 'Social Worker' blog will be changing its name to 'Children's Social Care and Support' blog. The blog will be for all those working across children's social care and support, in such areas as social work, ...

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This is recognised in academic research, and clinical practice. Diagnostic manuals such as the DSM-V and ICD-11 include difficulties with trust in criteria of mental health diagnoses some survivors receive such as Complex Post-Traumatic Stress Disorder (CPTSD), Post-Traumatic Stress Disorder (PTSD) and Borderline Personality Disorder (BPD). However these manuals place all of the onus on the survivor to trust and make no mention of the need for, and provision of, a trustworthy relationship.

Learning from my PhD study

My research indicates that it is not just the initial sexual abuse suffered in childhood that shapes the carefulness survivors use in professional relationships.

Most of the people I interviewed felt their caution resulted from difficult, oftentimes (re)traumatising interactions trying to disclose their abuse to professionals, family and friends and being met with disbelief, silence, disgust, shock, rejection, and denial. Difficult experiences disclosing had made survivors in this study increasingly careful and more circumspect when needing to trust again.

When such earlier disclosures had been made the survivors had trusted their listener enough to break the silence. is a well-documented aspect of survivor experience and is often the result of abuser grooming which utilises fear and shame to ensure the child keeps the abuse secret and the abuser safe.

If survivors are not believed when they disclose abuse, which may have taken years to feel safe enough to do, they may re-calibrate their parameters of who to trust, and what trustworthiness looks like in a professional.

If professionals then perceive survivors' difficulties in trusting as arising from experiences of abuse, we can easily fail to pay attention to the importance of being a trustworthy person offering care ourselves.

The importance of building transactional trust

The building of 'transactional trust' (Reina and Reina, 2009) is a first step towards building a full relational trust. Transactional trust refers to the trustor evaluating the trustee as a capable and reliable person in the context of a specific objective that the pair have come together to attain.

My research showed that from the first interaction onwards the survivor and their trustee are engaged together in 'relational entrusting', and this is entirely dependent on the behaviours of both parties in the relationship.

Furthermore, survivors most definitely could trust when certain requirements were fulfilled. In fact, they shared stories of many relationships where this had been possible and trauma healing ensued. One survivor said:

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Building trust with survivors of child sexual abuse

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The nature of developmental trauma caused by child sexual abuse stems directly from a breach of trust.

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What does alcohol do to the embryo?

As alcohol can impact on, and effect, any part of the embryo, it means that every person affected is affected uniquely. However, because we know that alcohol is most likely to have an effect on the 'midline' of the brain, we can see common traits, including:

poor impulse control,

difficulties with emotional regulation,

issues in retrieving and storing information,

issues in receptive language,

poor auditory functioning,

specific facial features called 'sentinel facial features'.

Many of the outcomes of pre-natal alcohol exposure can be mistakenly diagnosed as attention deficit hyperactivity disorder (ADHD), autism spectrum disorders (ASD) or post-traumatic stress disorder (PTSD) ( The Association for Child and Adolescent Mental Health, 2023 ). For children in the care system, FASD can be confused with attachment and trauma concerns. In order to provide the right adjustments and support to a person, it is vital that we know the correct cause, which could include, for example, both FASD and trauma (Mukherjee et al., 2019; Price et al., 2017).

Equally, those affected may not have a diagnosis of any condition whatsoever (Price, 2019) but may be viewed unfairly as 'naughty' children, with 'challenging' behaviours, or as being the result of 'poor parenting'. More information on pre-natal alcohol exposure and trauma research can be found in by Dr Alan Price from the University of Salford.

How common is FASD?

TheUK has some of the highest rates of alcohol exposure in the world for women drinking during pregnancy which can cause FASD (NICE, 2019). This is preventable and yet goes largely unappreciated. 'Binge drinking' culture is prevalent in the UK, and over the last few decades, we have also seen an equalisation between the way men and women consume alcohol. There are a number of reasons why women who are pregnant may continue to drink alcohol, including:

They might not know they are pregnant.

They might feel under pressure to drink when with friends.

They might be trying to cope with problems and stress.

They might not be aware of the risks of drinking alcohol during pregnancy.

Children and young people in care and adopted children are over-represented in terms of FASD (unsurprisingly as they often come from scenarios in their birth family where alcohol will have featured). Although accurate rates of prevalence are difficult to obtain, other research suggests it can be anything from 27% to 60% of children in the care system that may be affected (e.g. Gregory et al., 2015). This compares to rates for the whole population that again are unclear but thought to be anywhere between 1.8-3.6% (McCarthy et al., 2021) and 6-7.2% (McQuire et al., 2019).

Recent research, conducted by the University of Salford, suggests that the rate of FASD within society could be at least as common as autism (McCarthy et al. 2021).

What are we doing about FASD?

In March 2022, after many years of lobbying based on our increasing knowledge of the impact of alcohol on the developing fetus, the National Institute for Care and Health Excellence (NICE) issued a Quality Standard on FASD. This standard addresses five areas where local authorities, Commissioning Care Groups and Primary Health Trusts need to improve their services:

1. Prevention/education - Pregnant women are given advice throughout pregnancy not to drink alcohol.

2. Recording - Pregnant women are asked about their alcohol use throughout their pregnancy, and this is recorded.

3. Referral - Children and young people with probable prenatal alcohol exposure and significant physical, developmental, or behavioural difficulties are referred for assessment.

4. Diagnosis - Children and young people with confirmed prenatal alcohol exposure or all three facial features associated with prenatal alcohol exposure have a neurodevelopmental assessment if there are clinical concerns.

5. Care Management - Children and young people with a diagnosis of FASD have a management plan to address their needs.

Conclusion

It is vital that everyone working within social care, both adults and children, but particularly those working with children in, or on the edge of, the care system, know about FASD, how it is caused, how the brain can be affected and, most crucially, how they can support people who have been impacted.

A co-produced by young people with FASD explains how they would like people, including professionals like doctors, teachers, social workers and others, to better support people with FASD.

If you want more information about FASD, or wish to have training on FASD for professional staff, including foster carers, please visit the FASD training website or get in touch with the author at martin@fasdtraining.co.uk.

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Supporting people with Fetal Alcohol Spectrum Disorders

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Martin Clarke shares recent research and key messages about Fetal Alcohol Spectrum Disorders and how practitioners can support people who have been impacted.

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It is important to develop effective support for men, including boys, fathers and male carers. A new Research in Practice podcast explores services that successfully support men.

We all have circumstances and pressures that need to be understood so it's important we create services that work effectively, understand cultural identity and advocate for all men.

The explores a service being developed in Leeds City Council to work with fathers from a Black, Asian and minoritised ethnic background, with reflections from a father who took part in the Journey project. It explores experiences of working together, the importance of understanding someone's cultural identity, listening and sharing emotions.

The podcast is the third in a series of three podcasts about the journey Leeds is taking to improve its work with fathers.

The series shares examples of positive practice and provides advice for social workers looking to work more effectively.

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It is important to develop effective support for men, including boys, fathers and male carers. A new Research in Practice podcast explores services that successfully support men.

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Chief Exec update on Trust social work 09/06/23

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Chief Exec update on Trust social work 09/06/23

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Social Work in Disasters online training

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This training is designed to provide social workers/social work students with an overview of social work in disasters

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What's worse than experiencing harassment related to your identity? Whether it's about your race, color, religion, or immigration status; about your gender presentation or sexual orientation; about your size, age, or a disability you live with? Well, what's worse than being harassed in public is being surrounded by bystanders who see it happening, but do nothing about it.

It doesn't have to be that way.

In recent history, we've been witnessing a spike in disrespect, harassment, and hate violence. As bystanders, we must be especially vigilant and aware of what these harms can look like, so that we're ready to stand up and intervene.

When we intervene, not only do we reduce the trauma of harassment for the person who was harmed (yes, harassment can cause trauma!)...we also slowly chip away at the culture of harassment, and replace it with one of humanity.

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harassment training requirements by state

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What's worse than experiencing harassment related to your identity? Whether it's about your race, color, religion, or immigration status; about your gender presentation or sexual orientation; about your size, age, or a disability you live with? Well, what's worse than being harassed in public is being surrounded by bystanders who see it happening, but do nothing about it.

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City Social Care mental health teams/ mental health act assessment contact details 

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City Social Care mental health teams/ mental health act assessment contact details 

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Mental Heath Social Care Team South Stonebridge Centre Cardiff Street Carlton Road Nottingham NG3 2FH
Tel: 0115 9560849

Mental Heath Social Care Team North Ivy Suite Highbury Hospital Nottingham NG6 9DR
Tel: 0115 9560849
mentalhealthnorth@nottinghamcity.gov.uk

Mental Health Act assessment referrals: mentalhealthnorth@nottinghamcity.gov.uk

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Informal Carers Referrals

From Monday 2 nd October 2023 who we make referrals to will change.

All referrals for informal Adult Carers for Carers Assessments and support will be made to:

Carers Federation Adult Carers Hub (carers age 18+)

Call Adult Carers Hub: 0808 802 1777

WhatsApp or Text: 07814678460

Email Referrals: achreferrals@carersfederation.co.uk

General Email: achinfo@carersfederation.co.uk

Address: Carers Federation, Christopher Cargill House 21-23 Pelham Road Nottingham NG51AP

Office Hours: Mon to Fri 9am until 5pm (out of hours TBC)

Website: adultcarershub.carersfederation.co.uk

Facebook: Carers Federation

(X Formerly Twitter):   Carers Federation

LinkedIn: Carers Federation

If a referral is needed for a Young Carer these will be made to:

Young Carers Notts ( carers aged 5-17)

Call Young Carers: 0115 824 8824

WhatsApp or Text: TBC

Referrals/ General Email: youngcarers@tuvida.org

Address: 54A Nottingham Road Mansfield NG18 1BN

Office Hours: Mon – Fri 9am-5pm (out of hours TBC)

Website: TuVida – supporting your life

Facebook: Nottinghamshire  Young Carers

Instagram: Nottinghamshire Young Carers

Contact Information for Adults Carers Hub

Carers Federation Referral Form

New Carers Support Services

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Nottingham Financial Resilience Partnership (money, debt, finance, income, credit)

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Nottingham Financial Resilience Partnership (money, debt, finance, income, credit)

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Nottingham Financial Resilience Partnership | Financial Wellbeing

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Nottingham Financial Resilience Partnership is a partnership of organisations in the city who support people's financial wellbeing.

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Changing Futures Nottingham for Severe Multiple Disadvantage (SMD, discrimination, poverty, homelessness, mental health, substance and alcohol issues, sexual or domestic abuse)

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Changing Futures Nottingham for Severe Multiple Disadvantage (SMD, discrimination, poverty, homelessness, mental health, substance and alcohol issues, sexual or domestic abuse)

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Changing Futures. Believing in people, inspiring change

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At Changing Futures we believe that people experiencing multiple needs should have access to appropriate services when and for as long as they need to.

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Information for Social Work Teams about the Illegal Migration Bill

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Information for Social Work Teams about the Illegal Migration Bill

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Social work in disasters training | www.basw.co.uk

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Social Work in Disasters online training

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This training is designed to provide social workers/social work students with an overview of social work in disasters

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Overview | Supporting adult carers | Guidance | NICE

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This guideline covers support for adults (aged 18 and over) who provide unpaid care for anyone aged 16 or over with health or social care needs. It aims to

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Neurodiversity and Radicalisation Briefing - Final January 2023

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Good Practice Guidance Managing Risks Associated with Multiple perpetrators of abuse v5_refreshed Jan 2023

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BME Network | Nottinghamshire Intranet (nottshc.nhs.uk)

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BASW England Peer Support Forums for Social Workers in Health

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This open forum is being supported by the Social Work in Health Thematic Group. Forums may have guest speakers focusing on specific themes for the first half hour with the second half of the session opening out for general discussion, peer support and reflection. See individual dates for details.

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Guide to carers and confidentiality- NottsHC guidance

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Guide to carers and confidentiality- NottsHC guidance

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Carers guide to confidentiality and info sharing

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National Workforce Census of Social Workers and Social Care Workforce within Mental Health Services May 2023

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National Workforce Census of Social Workers and Social Care Workforce within Mental Health Services May 2023

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Social Workers and Social Care Workforce within mental health services May 2023- National report - Accessible

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Anti-racist practice SW forum 26.06.23 (002)

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MCA - Information that needs to be understood for a range of decisions 

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MCA - Information that needs to be understood for a range of decisions 

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Right Care, Right Person (Police guidance/ thresholds for responding to mental health incidents)

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Right Care, Right Person (Police guidance/ thresholds for responding to mental health incidents)

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When people are in mental health crisis, they need timely access to support that is compassionate and meets their needs. While there will always be cases where the police need to be involved in responding to someone in mental health crisis (for example, where there is a real and immediate risk to life or serious harm, or where a crime or potential crime is involved), police are increasingly involved when they are not the most appropriate agency to respond, and they are not able to handover care to a more appropriate professional in a timely manner. This impacts on the ability of the police to carry out their other duties effectively, and importantly, can result in people with mental health needs experiencing greater distress and having poorer experiences of the mental health care pathway.

The establishment of the Crisis Care Concordat and the expansion and improvement of mental health services, supported by investment through the NHS Long Term Plan, means that more people who require care and support are able to access this in an appropriate setting and from the right professional. However, this is not yet universally the case and there is scope for improvement through new ways of cross-agency and joined-up working.

This agreement sets out a collective national commitment from the Home Office, Department of Health & Social Care, the National Police Chiefs' Council, Association of Police and Crime Commissioners, and NHS England to work to end the inappropriate and avoidable involvement of police in responding to incidents involving people with mental health needs. Where it is appropriate for the police to be involved in responding, this will continue to happen, but the police should only be involved for as long as is necessary, and in conjunction with health and/or social care services.

The strategic approach described in this document, 'Right Care, Right Person' ( RCRP) provides a framework for assisting police with decision-making about when they should be involved in responding to reported incidents involving people with mental health needs. RCRP has already been implemented in a number of local areas and can help to successfully reduce inappropriate police involvement in care and support better access to mental health specialists.

While each police force is operationally independent, many forces across England are beginning to adopt the RCRP approach. To successfully adopt the approach, strong partnerships need to be formed between police forces, health bodies and local authorities to identify how to implement this approach in a way that best meets the needs of the local population and the shared aims of the agencies involved. To supplement the strategic approach set out in this document, the National Police Chiefs' Council, College of Policing, and NHS England are producing detailed guidance to support local areas with the operational delivery of RCRP.

The Right Care, Right Person approach

Right Care, Right Person is an approach designed to ensure that people of all ages, who have health and/or social care needs, are responded to by the right person, with the right skills, training, and experience to best meet their needs. Though the approach can be applied more broadly than cases relating to mental health, this document is focused on the interface between policing and mental health services, as one step towards implementing RCRP.

At the centre of the RCRP approach is a threshold to assist police in making decisions about when it is appropriate for them to respond to incidents, including those which relate to people with mental health needs. The threshold for a police response to a mental health-related incident is:

to investigate a crime that has occurred or is occurring; or

to protect people, when there is a real and immediate risk to the life of a person, or of a person being subject to or at risk of serious harm .

The approach involves consistent use of the RCRP threshold to determine whether the police are the appropriate agency to respond at the point at which the public or other professionals report a mental health-related incident (e.g. via a call made to the police). It is important to distinguish this from the police's powers under the Mental Health Act 1983 (MHA), e.g. section 136. While the decision to attend an incident is determined by assessing that the incident meets the RCRP threshold, the decision to use powers under the Mental Health Act, is made by an officer at the scene of an incident. Partnership arrangements governing police involvement at pre-planned interventions will continue to be managed at a local level, e.g., police attendance at section 135 MHA warrants. The police will always have the discretion to deploy to incidents and this document does not impede the operational independence of chiefs.

The RCRP threshold should be used in a way that is responsive to dynamic and changeable situations. For example, there may be occasions where a call handler initially judges that there is no clear and immediate risk of serious harm, but the situation escalates. As with all other types of incidents, the police will apply a continuous risk assessment approach, and respond as required to any change in risk, taking into account any information provided by local partners. Likewise, when the police have responded to an incident, but the threshold is no longer reached, there should be a timely transfer of support to mental health or other suitable services, with local areas working towards handovers taking place within one hour as specified in local plans (unless mutually agreed in relation to a particular incident on a case-by-case basis).

Importantly, RCRP may be used in conjunction with appropriate joint-working models that are set up between the police and health agencies locally. Examples of effective and appropriate joint working include statutory Liaison and Diversion services and locally developed health-led triage models. These services, which have a role in ensuring people access the right support, are separate from and can co-exist alongside the use of the RCRP approach.

Local partnership working to implement Right Care, Right Person

It is crucial that at the heart of planning and implementing RCRP for people with mental health needs, there is a focus on ensuring patient safety is maintained and people in mental health crisis are not left without support. This means the approach to RCRP implementation for people with mental health needs should be planned and developed jointly through cross-agency partnerships before changes to responses are introduced. While police forces will ultimately determine the timeframe for implementing the RCRP approach locally, it should be established following engagement with health, social care and other relevant partners. Once implemented, locally developed arrangements should be monitored and reviewed over time.

Implementation should be designed with due regard to the public sector equality duty and the NHS England Patient and Carer Race Equality Framework. In particular, implementation should help support the reduction of people from ethnic minorities in the urgent mental health pathway, who disproportionately experience restrictive interventions and are more likely to access mental health care via the criminal justice system. Consideration should also be given to ensuring that the way that each incident is risk assessed against the RCRP threshold is appropriate for individual needs, for example in relation to children and young people, older adults, people with a learning disability and people who are neurodiverse, including autistic people.

The signatories of this agreement intend that the cross-agency partnerships set up in each area to implement the RCRP approach for people with mental health needs work together on achieving the following:

Agreeing a joint multi-agency governance structure for developing, implementing, and monitoring the RCRP approach locally. People with lived experience of the urgent mental health pathway, including those from ethnic minorities, should form part of the governance structure and be actively engaged in considering how RCRP is implemented. In addition, from a health system perspective, Integrated Care Boards will play a key role in coordinating the approach to supporting the implementation of RCRP.

Reaching a shared understanding of the aims of implementing RCRP locally and the roles and responsibilities of each agency in responding to people with mental health needs. Given that 'mental health needs' covers people with a broad spectrum of needs, this should include agreeing what is the remit of health services (primary care and secondary mental health services), local authority services (including social care and substance misuse services), and voluntary, community and social enterprise organisations.

Enabling universal access to 24/7 advice, assessment, and treatment from mental health professionals for the public (via the NHS111 mental health option), as well as access to advice for multi-agency professionals, including the police, which can help to determine the appropriate response for people with mental health needs. Plans should be put in place to communicate the availability of this advice to the public and other organisations/professionals locally, who may otherwise call the police as their first point of contact.

Putting in place arrangements to work towards ending police involvement in the following situations, where the RCRP threshold is not met:

initial response to people experiencing mental health crisis.

responding to concerns for welfare of people with mental health needs (i.e., undertaking welfare checks), where the person is already in contact with a mental health service or other service commissioned to provide mental health support.

instances of missing persons from mental health facilities, and walkouts of people with mental health needs from other health facilities (e.g., the Emergency Department).

conveyance in police vehicles.

Embedding multi-agency ways of working that can support decision-making about which service or services are most appropriate to respond to an incident reported to the emergency services (e.g., whether it is police, ambulance, or mental health services, or a joint agency response). For example, health-led, integrated multi-agency triage of 999 calls that enables shared decision-making has been shown to be effective in reducing avoidable police deployment, use of section 136 MHA and police conveyance.

Ensuring arrangements are in place to minimise delays to handovers of care between the police and mental health services. Currently, there can be significant delays in accessing appropriate mental health expertise and facilities, particularly at evenings and weekends, and when someone is detained under section 135 or 136 of the MHA. These delays are detrimental to the person with urgent mental health needs and the family or friends supporting them and impacts on police capacity to fulfil wider duties. Systems should look to reduce these delays as far as is safe to do so, working towards a timeframe of one hour as specified in local plans (unless mutually agreed in relation to a particular incident on a case-by-case basis).

Developing an approach for police and health systems to work together to quickly and efficiently identify the best place to take a person detained under section 136 of the MHA, to reduce time spent on conveyance.

Developing local escalation protocols for situations including: significant system delays that result in people being inappropriately under the care of the police when they should be accessing mental health support; detentions in custody (all areas should be ending the practice of detaining people with mental health needs in police cells); and reoccurring situations where health partners feel the RCRP threshold is met but a police response is not provided. Protocols should include information on how to escalate urgent issues that cannot be resolved locally and processes for identifying reoccurring issues that indicate a system change is required.

Establishing effective mechanisms to support data collection and sharing across agencies, to inform the development and implementation of RCRP, including any changes required to ways of working and wider-system resourcing. The data should enable an understanding of local urgent and emergency mental health need, current levels of police involvement in mental health related pathways, and the impact of the changes introduced under RCRP, both operationally and in terms of the experiences and outcomes of people requiring urgent mental health support. This includes monitoring the impact for people from ethnic minorities, and other groups with specific needs, such as children and young people, and autistic people, and taking action where inequitable impact is identified.

Developing multi-agency training to support decision making and understanding of roles and responsibilities in relation to RCRP, as well as the Mental Health Act.

National support for implementation of Right Care, Right Person

To support local implementation of Right Care, Right Person for people with mental health needs, The National Police Chiefs' Council and College of Policing are currently developing a national toolkit, covering topics including decision-making in relation to the RCRP threshold for police response, partnership working, training requirements, and data standards and evaluation. In tandem, NHS England are co-producing guidance with multi-agency professionals and people with lived experience of mental health problems, on how to strengthen the interface between multi-agency partners within the urgent mental health pathway.

There will also be an evaluation of the rollout of the RCRP approach for people with mental health needs. Findings from this evaluation, as well as wider learning about good practice from local partnerships across the country, will be shared to support successful implementation.

Rt Hon Chris Philp MP, Minister of State for Crime, Policing and Fire

Maria Caulfield MP, Parliamentary Under Secretary of State for Mental Health and Women's Health Strategy

Deputy Chief Constable Rachel Bacon, NPCC Mental Health Lead

Claire Murdoch, National Mental Health Director, NHS England

Lisa Townsend, Police and Crime Commissioner, APCC Mental Health lead

Andy Marsh QPM, Chief Executive Officer, College of Policing

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National Partnership Agreement: Right Care, Right Person (RCRP)

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When people are in mental health crisis, they need timely access to support that is compassionate and meets their needs.

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This is a space for all NottsHC Trust social workers to share information, developments and best practice.

It is owned by all of us- you do not need permission to post and this should be fully editable by everyone. It is asked that you please update your information in the "Who Are We" section so we can have a better understanding of where social work colleagues exist within the Trust and please do keep this updated.

Please use the search button in the top right to filter all posts by topic if you're looking for specific guidance or resources (please note you will have to scroll right to see what shows up under each section heading). If a link is blocked by the Trust servers, try opening it in the Chrome browser instead of Edge! If a document has embedded items you can't open, right click on it and download it so it opens outside of the internet browser.

If you're adding resources, please add any key works into the title so it will come up on searches (i.e. beds/ white goods/ homelessness/ carers etc).

Please note if you add Connect links you will only be able to see them if you are logged in to the Trust network.

To edit a post hover near the three black dots in the top right- the edit button will then appear. To add a new post click the + button under the relevant heading.

There is also a separate MSTeams "Trustwide Social Work Forum" chat group where colleagues can post to reach out to other social workers, share information and seek professional guidance and support. If you share any helpful resources on the chat please do add them here so they are easy to access!

If you need help or advice on how to add to or amend this Padlet please reach out on the Trustwide MSTeams chat above for support.

If new social work colleagues join please share this resource with them by sending them the weblink- this is open access so they don't need to be added as a member.

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Student Support Process - Flowchart 2023

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Domestic Abuse DASH RIC & MARAC Referral Form (Domestic Abuse) (Adult) (MARAC) (Nottinghamshire) (Nottingham)

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Domestic Abuse DASH RIC & MARAC Referral Form (Domestic Abuse) (Adult) (MARAC) (Nottinghamshire) (Nottingham)

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Equation (Domestic Abuse Support for Whole Communities)

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Equation (Domestic Abuse Support for Whole Communities)

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(Men) (Children) (Women) (LGBTQ+) (Domestic Abuse)

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Hide the Signs You've Been on This Website

Internet browsers normally save certain information as you use the Internet. This includes words you've searched, and a history of the sites you've visited. If you're worried that someone at home will look at what you've done online, the safest option is to use a computer at a local library, a friend's house, or at work. You can also reduce the chance that someone will discover your internet activities by following these instructions to clear your internet history.

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Equation | Domestic Violence Nottinghamshire

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Hide the Signs You've Been on This Website Internet browsers normally save certain information as you use the Internet. This includes words you've searched, and a history of the sites you've visited. If you're worried that someone at home will look at what you've done online, the safest option is to use a computer at a local library, a friend's house, or at work.

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Juno Women's Aid (Nottinghamshire) (Nottingham)

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Juno Women's Aid (Nottinghamshire) (Nottingham)

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(Domestic Abuse) (Children and Families) (Adults)

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Juno Women's Aid Nottingham & Nottinghamshire

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Domestic Abuse & Violence Helpline, Support, Charity in Nottingham | Juno - Juno Women's Aid Nottingham & Nottinghamshire

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JUNO Women's Aid empowers women and children to live free from abuse and violence. 24h Free Helpline 0808 800 0340. Nottingham and Nottinghamshire.

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Nottinghamshire Independent Domestic Abuse Services (NIDAS)

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Nottinghamshire Independent Domestic Abuse Services (NIDAS)

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(Domestic Abuse) (Children) (Adolescents) (Adults) (Adult safeguarding) (child safeguarding)

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NIDAS - Nottinghamshire Independent Domestic Abuse Services

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NIDAS supports women and families with all aspects of domestic abuse. We believe being free from abuse is only the start of the journey. We support those affected to stay safe, grow their self-esteem and go on to build happy, healthy relationships. Our team, work in a kind, caring and non-judgmental way, providing personalised support as needed.

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Home - NIDAS - Nottinghamshire Independent Domestic Abuse Services

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Breaking the cycle of domestic abuse through trusted, confidential & bespoke services.

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Young Persons DASH RIC (children) (domestic abuse) (risk assessment)

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Young Persons DASH RIC (children) (domestic abuse) (risk assessment)

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Transforming Care- Notts Dynamic Support Register guidance ("Blue Light"/ LAEP/ inpatient/ autism/ learning disability)

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Transforming Care- Notts Dynamic Support Register guidance ("Blue Light"/ LAEP/ inpatient/ autism/ learning disability)

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Notts Dynamic Support Register guide (Blue Light- LAEP process)

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Transforming Care- "Blue Light"/ LAEP/ Care and Treatment Review Protocol- NHS England (inpatient/ autism/ learning disability guidance)

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Transforming Care- "Blue Light"/ LAEP/ Care and Treatment Review Protocol- NHS England (inpatient/ autism/ learning disability guidance)

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Social Work England (SWE) Professional Standards

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Social Work England (SWE) Professional Standards

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The ‘Guide to coroner services’ is intended for bereaved people and others who may be affected by a coroner investigation or are attending a coroner’s inquest.

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Working definition of trauma informed practice- Gov.uk

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Working definition of trauma informed practice- Gov.uk

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Office for Health Improvement and Disparities

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Working definition of trauma-informed practice

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Trauma-informed approaches have become increasingly cited in policy and adopted in practice as a means for reducing the negative impact of trauma experiences and supporting mental and physical health outcomes. They build on evidence developed over several decades. However, there has been a lack of c…

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Implementing the Workforce Race Equality Standard (WRES) is a requirement for NHS commissioners and NHS healthcare providers including independent organisations, through the NHS standard contract.

The NHS Equality and Diversity Council announced on 31 July 2014 that it had agreed action to ensure employees from black and minority ethnic (BME) backgrounds have equal access to career opportunities and receive fair treatment in the workplace.

This is important because studies shows that a motivated, included and valued workforce helps deliver high quality patient care, increased patient satisfaction and better patient safety.

In April 2015, after engaging and consulting with key stakeholders including other NHS organisations across England, the WRES was mandated through the NHS standard contract, starting in 2015/16. From 2017, independent healthcare providers are required to publish their WRES data.

The first WRES report, was published in June 2016, followed by the 2016 WRES report on 19 April 2017. In the first two years, there have been improvements in some trusts, although a number of organisations still have a long way to go. The 2017 and 2018 WRES data reports showed a trend of continued improvement in a number of areas, but there is still much work to do in some trusts, sectors and parts of the NHS.

The 2022 WRES data report compares data from previous years to assess trends.

NHS providers are expected to show progress against a number of indicators of workforce equality, including a specific indicator to address the low numbers of BME board members across the organisation.

The first phase of the WRES focused on supporting the system to understand the nature of the challenge of workforce race equality and for leaders to recognise that it was their responsibility to help make the necessary changes.

WRES phase two

The next phase of the WRES will focus on enabling people to work comfortably with race equality. Through communications and engagement, we will work to change the deep rooted cultures of race inequality in the system, learn more about the importance of equity, to build capacity and capability to work with race.

Continuous embedding of accountability to ensure key policies have race equality built into their core, so that eventually workforce race becomes everyday business.

The WRES will continue to work to evidence the outcomes of the work that is done, publishing data intelligence and supporting the system by sharing replicable good practice.

With over one million employees, the NHS is mandated to show progress against a number of indicators of workforce equality, including a specific indicator to address the low numbers of BME board members across the organisation.

Alongside WRES, NHS organisations use the Equality and Diversity Systems (EDS2) to help in discussion with local partners including local populations, review and improve their performance for people with characteristics protected by the Equality Act 2010. By using the EDS2 and the WRES, NHS organisations can also be helped to deliver on the Public Sector Equality Duty.

More information to help you understand the WRES, downloadable information, videos and EDS2 can be found in our resources section.

WRES reporting

From 2018, WRES data is collected through the NHS Digital Strategic Data Collection Service (SDCS), which replaced UNIFY 2 the previous platform.

Get in touch

If you have questions about the WRES Programme, please contact the National WRES Implementation Team england.wres@nhs.net.

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NHS England » NHS Workforce Race Equality Standard

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Implementing the Workforce Race Equality Standard (WRES) is a requirement for NHS commissioners and NHS healthcare providers including independent organisations, through the NHS standard contract.

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The Anti-Racist Listening Project (anti-racist social work practice podcast)

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The Anti-Racist Listening Project (anti-racist social work practice podcast)

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‎The Anti-Racist Listening Project on Apple Podcasts

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Social Workers Without Borders- support for asylum seekers and refugees.

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Social Workers Without Borders- support for asylum seekers and refugees.

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County Lines (adult and child safeguarding/ abuse/ grooming/ exploitation)

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County Lines (adult and child safeguarding/ abuse/ grooming/ exploitation)

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Whiteness: a problem for out time 2021 (white privilege/ white fragility/ psychoanalytic view/ anti racist practice)

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Whiteness: a problem for out time 2021 (white privilege/ white fragility/ psychoanalytic view/ anti racist practice)

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The Tavistock and Portman NHS Foundation Trust

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Whiteness   a problem for our time - January 2021 policy seminar

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We'd love to show you how your support is helping LGBTQ+ people everywhere to thrive. We need your consent to keep you up to date with our campaigns and events, and what you can do to help make life better for LGBTQ+ people.

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At Stonewall, we stand for lesbian, gay, bi, trans, queer, questioning and ace (LGBTQ+) people everywhere. We imagine a world where all LGBTQ+ people are free to be ourselves and can live our lives to the full.

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Headway (brain injury support and information)

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Headway (brain injury support and information)

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brain injury head injury concussion coma traumatic brain injury rehabilitation legal compensation support uk headway

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Headway is the UK-wide charity that works to improve life after brain injury by providing vital support and information services.

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Black Lives Matter UK site (BLM/ racism/ discrimination/ equality and liberation)

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Black Lives Matter UK site (BLM/ racism/ discrimination/ equality and liberation)

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We believe in the power of imagery to change the world and we choose to amplify imagery for positive change with Agora

#StopRacism by Agora photographers worldwide

Now more than ever, the world is taking a stand against racism, Agora photographers included!

2,120 photos have been submitted from all corners of the world, and 48 were selected to make it to the final voting rounds.

Click image to see all the finalist photos, discover the stories behind the pictures and learn a little more about Agora.

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Disclaimer: We are not affiliated with either Black Live Matter USA nor the political arm of the Black Lives Matter Activist Coalitions UK associated and affiliated with USA.

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The Diversity Trust (research and evidence around social change/ equality/ LGBTQ+/ Black Lives Matter)

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The Diversity Trust (research and evidence around social change/ equality/ LGBTQ+/ Black Lives Matter)

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Cyflwyniad - Introduction

Adnodd ar-lein i staff a rheolwyr cartrefi gofal ar sut i ddarparu amgylchedd gofal cynhwysol i bobl hŷn sy'n arddel hunaniaeth Lesbiaidd, Hoyw, Ddeurywiol, neu Draws (LHDT+).

Online learning materials and films for making care homes more inclusive for older LGBT+ people in England and Wales. A joint project between the Diversity Trust and the University of Bristol.

"Nod y prosiect oedd creu dwy ffilm fer fyddai'n dangos safbwyntiau oedolion hŷn lesbiaidd, hoyw a deurywiol, ac oedolion hŷn traws, ond yn y pen draw fe gynhyrchwyd adnodd llawer ehangach, sydd wedi'i dderbyn yn eang hefyd." Prifysgol Bryste - i weld adolygiad llawn, cliciwch yma

" The project set out to create two short films capturing LGB and trans older adults' perspectives, but produced a much more comprehensive, and comprehensively adopted, resource. " University of Bristol - for a full review,

Care Under the Rainbow Films

Trans Ageing and Care (TrAC) Project Films

Supporting Documents

The supporting documents for the Care Under the Rainbow project can be downloaded here. These documents are available in English and Welsh (Cymraeg).

English

Cymraeg

Course Programmes

For more information about our training on LGBT+ inclusion please click here

Read our event feedback LGBT+ & Ageing Event Report March 2023

Blog - Care Under the Rainbow

Read our blog post from Dr Paul Willis and Dr Wenjing Zhang, from the School for Policy Studies, University of Bristol, about the C LGBT+ & Ageing Event Report March 2023are Under the Rainbow project read here

Policy and Research Background

Read more about the research background to the project from the University of Bristol please follow this link to the research and policy briefing papers click here

Read more about the research background from the Diversity Trust community-based research projects click here

Care Quality Commission (CQC)

Read the supportive message, from Debbie Ivanova from the CQC, in support of our ongoing work CQC Message for 17 Mar 2021

Trans Ageing and Care (TrAC) Project

Dr Paul Willis (School for Policy Studies, University of Bristol), Dr Michele Raithby & Dr Christine Dobbs (Centre for Innovative Ageing, Swansea University).

About the research: Stonewall estimates that around 1% of the population identify as trans, including people identifying as non-binary, though there are no accurate estimates of the number of trans people in the UK. The recent UK survey of over 108,000 LGBT+ respondents commissioned by the UK Government (2018) indicates that trans respondents (13% of the sample) report lower life-satisfaction scores than the general population. Very little is known about trans people's health and social care needs in later life and not much attention has been given to issues associated with trans ageing. The objective of this two-year study was to better understand what the health and social care needs are of trans adults (50+ years of age) and to examine whether current health and social care services providers and professionals are meeting those needs in Wales.

Here is the link to the project website http://trans-ageing.swan.ac.uk/

Contact Dr Paul Willis for more information about the TrAC Project (Email) mailto:paul.willis@bristol.ac.uk

Pride in Care from Opening Doors London

Opening Doors are working to improve the quality of care and support for olden Lesbian, Gay, Bisexual and Trans People through Pride in Care. Pride in Care is a quality standard awarded to organisations assessed as providing quality care and support to older LGBT+ people. The registered quality mark is an externally verified seal of approval publicly demonstrating commitment to the continuous improvement of care for older LGBT+ people. You can find out more about Pride in Care on the ODL website, visit https://www.openingdoorslondon.org.uk/pride-in-care-quality-standard

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Care Under the Rainbow - The Diversity Trust

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We are specialists in diversity and inclusion training. We provide support services, policy and research to the private, public and third sectors.