Statutory guidance

Discharge from mental health inpatient settings

Published 26 January 2024

Applies to England

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), ^{[footnote 1]} 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^{[footnote 2]} 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^{[footnote 3]} 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^{[footnote 4]}. 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.

If the person lacks capacity to make decisions about their discharge and a Lasting Power of Attorney (LPA) is in place or a deputy has been appointed who has the relevant authority, the attorney(s) or deputy(ies) need to make best interest decisions around discharge. Any best interest decisions must be made in line with the Mental Capacity Act’s (MCA) principles and section 4 of the MCA. A referral to an independent mental capacity advocate may be required in certain cases (for more information, see section 3 ‘Mental capacity considerations’).

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^{[footnote 5]}. 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.

People who are detained in hospital for treatment under section 3 of the Mental Health Act, or are unrestricted Part 3 patients (patients concerned in criminal proceedings or under sentence), may be considered for a CTO on discharge from hospital. Although people do not have to give formal consent to this, people should be involved in discharge planning as much as possible, including decisions about CTOs, and they should be provided with information regarding CTOs.

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.

In some cases, it may be appropriate for an independent advocate to support an individual during the discharge planning process, and this may be a legal requirement under the MCA. Referrals to independent advocacy services should be made as soon as discharge planning begins and ideally upon admission, or where there is a legal duty to provide an IMCA as soon as the legal criteria applies. If there is a deputy or attorney with authority to make relevant decisions about discharge, then that individual is the best interests decision maker for the purposes of the MCA. In addition to support from an advocate, it may be appropriate for individuals to seek legal advice and support.

Annex B: national guidance on how budgets and responsibilities should be shared to pay for section 117 aftercare (Mental Health Act 1983)

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)

The duty to provide aftercare services continues as long as the person is in need of such services. In the case of a person on a CTO, aftercare must be provided for the entire period they are on the CTO, but this does not mean that the person’s need for aftercare will necessarily cease as soon as they are no longer on a 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.

This guidance will not repeat what is described in the National Framework, however it is helpful to highlight some key points. Where an individual is eligible for services under section 117 of the Mental Health Act 1983, these must be provided under section 117 and not under CHC. It is important for ICBs to be clear in each case whether the individual’s needs (or in some cases which elements of the individual’s needs) are being funded under section 117, CHC or any other power.

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

Individuals being released from prison, an IRC or the Youth Justice Estate who have a section 117 aftercare entitlement should be referred by the prison mental health team or IRC healthcare team to the relevant ICB and local authority as soon as is practicable so as to facilitate maximum opportunity for a section 117 aftercare plan to be drawn up prior to release.

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.

1. See the NCISH’s 10 ways to improve safety, which can support the quality and safety of inpatient care. ↩

2. Looked-after children are children subject to a care order under section 31 of the Children Act 1989 or accommodated by a local authority under section 20 of the Children Act 1989. ↩

3. All looked-after children must have a social worker and any child that is known to a local authority as being ‘at risk’ will have a social worker. ↩

4. Further statutory guidance, Promoting the health and wellbeing of looked-after children, should also be followed. ↩

5. The government is introducing Regional Care Co-operatives as part of its reforms of children’s social care. If established in the local area, the Regional Care Co-operative should also be involved in discussion of cases where children are in care. ↩