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Reviewing Mental Health Discharge Arrangements

In March 2023, HIW published its report following a review assessing the quality of the discharge arrangements in place within Cwm Taf Morgannwg University Health Board (CTMUHB) for adult patients discharged from inpatient mental health services to the community.

Reviewing the quality of discharge arrangements from adult inpatient mental health units within Cwm Taf Morgannwg University Health Board

The report made 40 recommendations for improvement, and considering the review’s findings, we wanted to understand whether the issues identified were replicated throughout other mental health services across Wales. Therefore, we asked all health boards to consider the report and provide a response to the recommendations.

HIW received responses from all health boards and analysed the information and supporting evidence. There was variability in the quality and detail of responses, and it is our intention that this exercise will inform our ongoing assurance activity in relation to mental health services. The most significant issues requiring improvement by services relate to communication for discharge planning, staff access to electronic clinical records in a timely manner and post discharge monitoring. 

The areas of concern we have found during our review were:

Discharge planning arrangements

Overall, we received a poor level of assurance around the discharge planning processes in place. This included ward rounds, coordinated working and communication across teams, holistic approach to planning and preparing for discharge, and crisis or contingency planning processes. It is clear from this exercise that health boards must focus on strengthening their communication arrangements to facilitate essential sharing of information between teams about care and treatment planning during the hospital stay and following discharge, to maintain the safety of patients.

Patient clinical record management systems

The CTMUHB review report highlights significant concerns with the ability of staff to access electronic information in a timely manner, due to several systems in use. It is concerning to note that most health boards also have several electronic systems in place to record and share patient information. Subsequently, we cannot be assured that the findings in CTMUHB mental health services regarding accessing timely information are not reflected in other mental health services across Wales.

Most health boards were not clear whether all inpatient and community staff can access the different clinical record systems. It was also not clear whether all staff have received training and guidance to ensure a consistent and appropriate use of clinical records systems. This includes documenting fundamental patient care and treatment plans, as well as assessing and evaluating patient progress effectively. This, therefore, may pose a risk to patient safety due to challenges with access and ability to record and review patient information in a timely manner.

HIW believes that the issues regarding patient clinical record management systems should be considered and reviewed on an all-Wales basis. However, until there is a solution to this issue, it is pivotal that each health board considers their clinical record management systems across their mental health services, to ensure there are mitigations in place to communicate across teams safely and effectively. This is to reduce the risk of harm and to ensure that everything possible is being done to discharge patients safely from inpatient services, and that patients receive the correct care and support following discharge from hospital.

Post discharge monitoring

NICE Guidance states that on discharge from an inpatient unit, a discharge advice letter must be completed by the inpatient consultant psychiatrist and emailed to the patient’s GP within 24 hours of their discharge. Not all responses provided assurance to confirm effective compliance with this guidance. In addition, there was a mixed response to demonstrate that information is also being provided to patients to explain their rights to self-refer in line with the Mental Health (Wales) Measure 2010.

NICE Guidance also states that a discharge summary should be sent to the patient’s GP and any other services involved with patient care within a week after discharge. Whilst health board responses provided detail to confirm that discharge summaries were being sent out, it was not clear to whom the summary was being sent.

Most Health boards confirmed the arrangements in place to ensure that patients were being followed-up within three days of discharge, in line with national guidance. However, the responses demonstrated a lack of emphasis on audit arrangements to ensure compliance with national discharge monitoring guidance. We are therefore, not assured that health boards are able to assure themselves that their mental health services are compliant, and work is required to strengthen this across Wales.