People have faced “unacceptable” delays of more than three years before leaving mental health wards, despite being well enough to be discharged, a Ferret investigation has found.
Findings based on data released under freedom of information legislation from Scotland’s 14 health boards reveal thousands of instances of delay in people leaving psychiatric hospitals.
In the three year period from January 2018 to Dec 2020 there were 46 delays of more than a year. This included at least 13 people in 2018, 16 people in 2019 and 12 people in 2020.
In at least 17 instances, people were not able to leave a ward for more than two years after being signed off as fit to do so by a doctor. In the most extreme cases people were left living in limbo in mental health wards for three years or more.
In 2019 five people in the care of NHS Greater Glasgow and Clyde had been waiting for more than three years to be discharged for mental health wards and NHS Tayside reported five “episodes” of delayed discharge of more than three years. In 2020 one person in Greater Glasgow had been waiting for more than three years and a further five “episodes” of more than three years were reported in Tayside.
The figures highlight a postcode lottery system, with delays to discharge from mental health wards varying hugely around the country.
Disability and mental health charities said “urgent action” was needed to ensure everyone ready to leave hospital was able to move on. They claimed that better community-based therapeutic services would help lead to quicker and more “successful” discharges from hospital regardless of whether people were officially delayed or not.
They also called for hospital standards and therapeutic care – which Mental Welfare Commission inspections show are mixed across the country – to be raised where appropriate.
The Mental Welfare Commission said that though finding appropriate care and accommodation could be complex, it was “not acceptable” for people to spend years in hospital awaiting discharge.
Hospitals said they were working hard to address the situation but were hampered by the lack of community based, local authority funded, support available.
Lengthy delays can also be caused by the legal proceedings needed to put guardianship arrangements in place for people with dementia or profound learning disabilities. This is necessary for those who do not have a legal capacity to agree to be moved to supported accommodation. Other waits can be caused by social work and mental health officer shortages.
A delayed discharge occurs when a patient, clinically ready for discharge, cannot leave hospital because the other necessary care, support or accommodation for them is not readily accessible or cannot be funded.
The unpublished figures obtained by The Ferret detailed at least 2,601 records of people who faced delayed discharge from mental health hospitals. They included 499 people in 2018, 1048 people in 2019 and 1054 people in 2020. Some figures were only given as “less than five”.
In NHS Greater Glasgow and Clyde, Scotland’s largest health board area which takes patients from other areas, 295 people faced delayed discharges in 2019. In 2020 249 were recorded. Over those two years delays of more than six months were recorded 46 times. In six instances people were there more than three years later.
In Fife almost one in five patients waited for more than six months to be discharged with 13 instances of people waiting to be discharged for more than a year. Three people faced waits of more than two years.
More than one in five patients in Highland was delayed by more than six months, with three per cent of patients delayed for a year. A further three per cent were delayed by more than two years.
Other than Shetland and Orkney, which do not have mental health beds, NHS Ayrshire and Arran, NHS Lanarkshire and NHS Borders were the only health boards where no patients faced a delay in discharge of more than a year from 2018 to 2020.
NHS Lothian claimed it initially misunderstood the FoI and though it provided data, was not what was requested. Some health boards provided incomplete data and Lanarkshire only provided figures for “episodes” of discharge rather than patient numbers.
The problem of delays facing those well enough to leave mental health hospitals has been highlighted several times recently by the Mental Welfare Commission Scotland for Scotland.
In 2019 it conducted a full investigation into an 18-month delay to the discharge of a 59-year-old woman known as Mrs ST. The commission said this was due to a “prolonged disagreement between family, health professionals and the Health and Social Care Partnership (HSCP) about discharge plans”.
The report said a catalogue of errors caused the delay and it should have been “a few weeks” rather than 18 months. They included delays to appointing a care manager and a disregard for the wishes of the woman and her family for her to return to her own home. Social work plans to place her in a care home then had to be challenged, leading her brother to apply for a guardianship order.
Although a mental health officer should legally be appointed within 21 days to carry out the necessary assessment, in this case it took more than nine weeks. Medical records requested by the family solicitor were then delayed, and the level of support she required to return home was contested by the local authority.
A 2016 Mental Welfare Commission report – No Through Road – found almost a third of those patients (32 per cent) with learning disabilities were experiencing long waits for discharge from hospital.
A commission spokesperson said that following both the 2016 and 2019 reports it put in place a system to monitor discharges across Scotland for people with learning disabilities. It is now looking to extend the pilot to include those delayed from leaving mental health wards.
Claire Lamza, interim executive director of the Mental Welfare Commission, said: "We understand that some people need complex care and support, which can take time to put in place. But we are clear that a hospital is not a home, and having people stay for years in a hospital environment, often without all the facilities they should have, is not acceptable.”
Scotland-wide figures on delayed discharge are already available in terms of hospital bed days across all NHS wards. The latest figures for 2020/21 – published by the Scottish Government last month – show 79,650 (22 per cent) delayed discharge bed days in Scotland from mental health wards with the remaining 278,776 (78 per cent) attributable to other specialties not including mental health.
Carolyn Lochhead, communications manager at the Scottish Association of Mental Health (SAMH), said it had experience of long waits for care packages to be set-up.
“People in our services have also talked about difficulties in getting a care manager,” she said. “Once you have that sorted it can then take a while to get an assessment and meanwhile hospitals will not be able to discharge.
“The process of being detained [sectioned under the mental health act] can be a very difficult process. People have legal rights but if they are still struggling there can be an awful lot of take on so that’s why good access to advocacy is so important.”
She claimed the recent focus on creating a National Care Service – following an independent review of adult social care by Derek Freely – provided some hope of more joined-up services that would help prevent long delays in discharge.
Following the review the Scottish Government launched the £20m Community Living Change Fund aimed in part at speeding up discharge for people with learning disabilities and complex needs including autism, and for people who have enduring mental health problems.
Lochhead also called for action to address “mixed” standards in hospitals across the country adding: “What we want to see is for hospital stays to be at the correct standard and therapeutic level care.”
Jan Savage, campaigns director at disability charity Enable Scotland, said there was widespread acknowledgement that delays were due to the lack of appropriate community-based social care.
“But better is possible,” she added. “Enable Scotland has worked hard to support a number of individuals out of hospital – given the right type and amount of skilled support, there is no-one who cannot be supported to live in his or her own community.
“We know that the reform of adult social care is a priority for the Scottish Government, and we welcome the previously announced Community Living Change Fund to support this work. But we now need to see urgent action to get every person out of hospital and into their own home.”
John Linn, chief executive of Flourish House, a mental health recovery community, agreed that action was needed to address the issue.
The Glasgow-based community service supports about 350 people in total with severe mental illness, many of whom have spent long periods in hospital as a result.
Linn said: “There are undoubtedly challenges around finding accommodation that has appropriate levels of support that meets the needs of the individual.
“We’ve supported people who have been to visit supported accommodation projects that have fallen through for one reason or another which means the person is in hospital for months longer than clinically necessary. That doesn’t work for anyone. No-one wants people to be in hospital any longer than necessary.”
More investment in community-based services would help, he claimed. Flourish House was once one of three busy Glasgow services for those with mental illness run by the voluntary sector but following funding cuts is now the only one in the city.
“I think successful hospital discharge is more achievable if supported by a robust community programme, which includes clinical, accommodation or tenancy support, but also provides meaningful activity and social support and routes to mainstream opportunity such as work and learning,” he added.
“Flourish House would be keen to engage with the discharge planning process to introduce our services to more people prior to leaving hospital and creating a link to the community before they leave hospital. I’m sure other providers would also welcome this.”
Challeges with complex cases
A spokesperson for NHS Greater Glasgow and Clyde said it acknowledged a small number of patients “who have complex mental and physical health needs may experience delays in being discharged from hospital to appropriate packages of community care”.
They added: “Some delays may be incurred in an effort to match and tailor a person's needs to the extensive variety of community care options available, ensuring that each individual has the best prospect of a successful and sustained discharge from hospital.”
A spokesperson for NHS Tayside said discharge from inpatient mental health wards included “waiting for admission to care homes, social care assessment, provision of equipment or care at home services, specialist care and treatment outwith the local board area and housing solutions for people with complex care requirements”.
They added: “There are particular challenges within our learning disability inpatient services where patients may experience lengthy delays due to highly complex health and care needs.”
NHS Highland claimed the most frequent reason for delay was in finding suitable onward placement or accommodation. “We always aim to ensure that our patients are discharged to the right place to safely meet their unique needs and achieving this can take time past when they would otherwise be ready to leave the hospital,” they added.
Councillor Stuart Currie, Convention of Scottish Local Authorities’ (COSLA) health and social care spokesperson, said his organisation, along with the Scottish Government, had been involved in “ongoing discussions to ensure that both NHS and social care work together in a whole system approach to ensure we all deliver the best possible outcomes for individuals.”
A Scottish Government spokesperson said: “These are extremely complex delayed discharges, and we are clear every patient should get the support they need.
“We know these delays are very challenging, where significant packages of care often need to be linked to specialist accommodation, which sometimes has to be commissioned, specially designed or purpose built. This can take a considerable time for arrangements to be put in place while those concerned continue to receive appropriate care in a hospital setting.”
'I wanted to get well enough to get home and get support there.'
This September it will be five years since Aidan left Skye House, the adolescent mental health ward in Glasgow where he spent nine months. Now 21 years old, Aidan – who has a diagnosis of autistic spectrum disorder (ASD) – and his family are convinced it was not beneficial for him to spend so long in hospital.
Those who work with people who are severely mentally unwell are clear that psychiatric hospitals are life saving, and stress they are an essential aspect of treatment services. But campaigners have called for more investment in community services, arguing they are key to more successful hospital discharges, and allow people to rebuild their lives more quickly and sustain a recovery.
Aidan and his family believe wider availability of community treatment, suitable for someone with ADS, would have made a huge difference and avoided the trauma they say was caused by a long stay at Skye House. Aidan - though using only his first name - is speaking out in the hope his experience can help inform positive changes to the system for others.
Though previously high levels of distress have dissipated now, Aidan’s obsessive compulsive order has returned and he is isolated from others his age and unsure of what the future holds. “I just feel sort of numb,” says Aidan, who loves music and is interested in politics.
He and his aunt trace back the start of his mental health struggles to 2015, when his grandparents died just a year apart. By December that year the severity of Aidan’s depression – along with OCD and anxiety – saw him admitted to Skye House – Scotland’s only adolescent mental health unit – on a voluntary basis.
But his stay was fraught from the start, as he struggled to adapt to what he describes as a “pretty draconian regime” with his ASD leading to regular periods of high distress – described by autism specialists as emotional dysregulation.
He’d had no past contact with the criminal justice system but by mid January 2016 police were called due to behaviour staff considered to be verbally abusive. He and his aunt claim staff did not understand how to deal with his ASD.
After six weeks Aidan’s family supported his decision to return home and believe more treatment at this stage could have helped him recover. But without sufficient community support in place the situation soon deteriorated with Aidan becoming suicidal and having to be stopped from running into traffic on the road near his home.
He was readmitted to Skye House in February, this time under a short-term detention order for 28 days, but due to his autism, struggled to cope. Staff responded to challenging behaviour by regularly calling police throughout March and April.
In one incident he broke a table and claims he was threatened by police with being taken into custody. “The reason they were called was because I had destroyed property and because I used abusive language,” says Aidan. “I would get very highly agitated. But I felt staff just didn’t understand my condition.”
His aunt stressed her complaint is with the system, not individuals. But she maintains this should not have been necessary. “If you listen, reassure him, de-escalate as much as you can and let [the “melt-downs”] run their course,” she says. He has never been violent with anyone inside or outside the family and the people who now work with him in the community now have never expressed any concern.”
His father told a mental health tribunal in May that the environment at Skye House was contributing to his son’s distress and “challenging behaviour”. But it decided “on balance” to grant a compulsory treatment order.
Following this speech, occupational and psychological therapy sessions, only available to him on site, were put in place. De-escalation techniques were agreed so police would no longer be called.
“This started off well,” says McGurk. “But then Aidan’s OCD became very bad, he couldn’t get out of the shower because of all the rituals he had to carry out.” She says staff did little to resolve this and he started missing sessions and even meals.
The resident medical officer finally admitted that they lacked expertise in ASD and suggested a referral to a specialist psychiatric unit at St Andrew Heathcare, Northampton, which has attracted controversy in recent years, causing the family great concern.
Meanwhile, it was confirmed the treatment order was due for review in October. McGurk claims community social work said that even if it was lifted it would be a further 12 weeks before Aidan could leave, to allow support and benefits to be put in place.
But on the 7 September the family received a phone call out of the blue, letting them know Aidan could go home for good two days later. Funding for St Andrews had not been granted. It left them feeling previous decisions to keep in hospital were arbitrary.
“We feel Aidan would have progressed better at home with a robust, documented community support plan and some provision for short overnight stays once a month to provide respite support for the family,” says McGurk. If that had happened she believes he would have stayed more in touch with his friends would have better self esteem.
Aidan too struggles to feel positive about the experience. “When I was there [in Skye House] I was just thinking that I wanted to get home and get support there. It just felt like a very dark road that I was on.”
A spokesperson for NHS Greater Glasgow and Clyde said: We are very sorry to hear that this young man and his family are unhappy with aspects of his stay and for them they remain unresolved.”
They said they could not discuss his case due to patient confidentiality but claimed the safety of both patients and staff was a priority.
“The team at Skye House pride themselves on the care and treatment they offer young people,” they added. “Each patient has a care manager allocated to them, who meets with family and supports family throughout the young person’s time with us.
“Our mental health teams work hard to protect the needs and wellbeing of our patients with those of our staff. While there will be instances where the police will be called, this will be as a last resort, when the use of therapeutic support has not been able to deescalate a situation and there is a risk to a young person, other young people, or our staff or where a staff member feels they’ve experienced violence and aggression.
“We recognise that when a young person requires inpatient psychiatric care it’s a significant event for both them and their loved ones. We aim to work collaboratively with all families whilst within Skye House. We are happy to meet this young man and his family to discuss their concerns.”
This story was co-published with the Herald.
Cover image thanks to iStock/LucaLorenzelli. Image of Aidan thanks to his family.