Acute inpatient mental health care for adults and older adults

In 2019, the NHS Long Term Plan was published, together with the NHS Mental Health Implementation Plan, which set out ambitious, funded plans, to transform mental health services. Shortly after this, the COVID-19 pandemic began, which had a major impact across the health system, including mental health services. As a result of pandemic pressures and the increases in cost of living currently facing households, inpatient mental health services have experienced sustained rises in demand and acuity, which have been particularly challenging due to the current workforce pressures across the NHS. 

While adult and older adult acute inpatient mental health teams continue to work hard to deliver high-quality care in line with the commitments set out in the NHS Long Term Plan and NHS Mental Health Implementation Plan, feedback from those who work in and access these services indicates that while some people have positive experiences, others can experience issues accessing care that truly meets their needs and supports their recovery. This can include delays to accessing inpatient care and to being discharged, people being placed out of area where it can be challenging for friends and family to visit and disproportionate use of restrictive interventions. Furthermore, issues with the quality of care disproportionately affect certain groups of people, including people from ethnic minorities, people who have a learning disability, and autistic people.  

It is vital that every person who needs acute inpatient mental health care receives timely access to high-quality, therapeutic inpatient care, close to home and in the least restrictive setting possible. To support this, NHS England has produced this guidance to set out its vision for effective care in adult and older adult acute inpatient mental health services, together with resources and suggestions to support delivery. In this vision:  

• Care is personalised to people’s individual needs, and mental health professionals work in partnership with people to provide choices about their care and treatment, and to reach shared decisions.
• Admissions are timely and purposeful – When a person requires care and treatment that can only be provided in a mental health inpatient setting and cannot be provided in the community, they receive prompt access to the best hospital provision available for their needs, which is close to home, so that they can maintain their support networks and community links. The purpose of the admission is clear to the person, their carers, the inpatient team and any supporting services. 
• Hospital stays are therapeutic – People receive timely access to the assessments, interventions and treatments that they need, so that their time in hospital delivers therapeutic benefit. Care should be delivered in a therapeutic environment and in a way that is trauma-informed, working with people to understand any traumatic experiences they have had, and how these can be supported in hospital, in a way that minimises retraumatisation.
• Discharge is timely and effective – People are discharged to a less restrictive setting as soon as their purpose of admission is met and they no longer require care and treatment that can only be provided in hospital. For this to happen, there needs to be discharge planning from the very start of a person’s admission. There also needs to be a range of community support available and supported living options which meet different needs and enable people to maintain their wellbeing and live as independently as possible after discharge. 
• Care is joined up across the health and care system – inpatient services work in a cohesive way with partner organisations, at admission, during a person’s inpatient stay and to support an effective discharge, so that people are supported to stay well when they leave hospital. 
• Services actively identify and address inequalities that exist within their local inpatient pathway, in partnership with people from affected groups and communities. This must include ensuring that people are not prevented from accessing or receiving good quality acute mental health inpatient care simply because of a disability, diagnostic label or any other protected characteristic. 
• Services grow and develop the acute inpatient mental health workforce in line with national workforce profiles, so that inpatient services can offer a full range of multi-disciplinary interventions and treatment. Staff wellbeing, training and development should be supported, so that inpatient services are a great place to work and staff are enabled to offer compassionate, high quality care.  
• There is continuous improvement of the inpatient pathway – services strive to improve by making the best use of data, regularly developing, testing and refining change ideas using quality improvement methodology, and ensuring that service improvements are co-produced with people with experience of inpatient services and their carers. 

We know that across the country there are services already delivering care that meets a number of these aims. With both the substantial investment in mental health services as part of the NHS Long Term Plan, the Government setting out its intention to reform the Mental Health Act (MHA) in the draft Mental Health Bill, and the recent establishment of NHS England’s Mental Health, Learning Disability and Autism Inpatient Quality Transformation Programme, now presents a significant opportunity to ensure that across all elements of this guidance, services are delivering care that is of a standard that we would all be proud of, and always puts people accessing services and those close to them at its heart. 

Some perspectives on what good quality care means to people who have personal experience of acute mental health inpatient care, either directly or as a carer, are illustrated by these quotes: 

“I would like to have staff on the ward who are compassionate and engaged, who understand my whole holistic and individual needs, and provide therapies and various activities that are meaningful, helpful, are of interest to me, and which feel comfortable for me to do. They should also help me to get better and plan my aftercare so that I can manage when I leave hospital.”

“For me, ideal inpatient care is when staff are willing to meet me and my loved ones where we are at each day, without expectations or demands. It’s about the service understanding how the small and large decisions that they make can impact my relative and her wider network, and the service being willing to work with us to identify and achieve the best outcomes for my relative, understanding that her needs change and fluctuate.”

“Co-production needs to be at the heart of inpatient care. I want to see clinicians and professionals working with me and my carers as equal partners, to develop, deliver and keep under review the best possible inpatient care for my needs. I want to see mental health inequality addressed, through people with lived experience supporting services to meet the needs of people from diverse communities.”

“If I need to be admitted, I would like inpatient care that is person-centred and provided in a recovery-focused environment. My admission should be as short as possible so as to not cause unnecessary trauma and there need to be more places that I can go to if I can’t go straight home when I’m ready to leave hospital. The power structures in inpatient settings also have to change, so that power is shared with people on the ward, particularly when they are from a marginalised group.”

Purpose of this guidance

This is the first time that NHS England has published national policy guidance outlining its vision for inpatient mental health care for adults and older adults, including people who also have dementia, an alcohol or drug problem, a learning disability, autism and any other individual needs. The guidance is intended to support integrated care systems (ICSs) and providers of mental health acute wards and psychiatric intensive care units (PICUs) to meet the ambitions for acute mental health care set out in the NHS Long Term Plan and NHS Mental Health Implementation Plan, alongside existing legislation and acute mental health standards (see Appendix 1). 

It is hoped that this document will support partnership working between inpatient mental health services and crisis resolution home treatment teams (CRHTTs), community-based mental health and learning disability teams, and other services, including social care providers, local authorities, independent sector providers and voluntary, community and social enterprise (VCSE) sector organisations.  

The guidance has been developed in partnership with frontline clinicians and people who have lived experience of accessing inpatient services, either directly or as a carer (see contributors to this guidance).

Key NHS Long Term Plan commitments for adult acute mental health inpatient services:  

• Eliminate all inappropriate adult acute mental health out of area placements (a definition of these can be found on the FutureNHS platform (requires login).
• Improve the therapeutic offer from inpatient mental health services by enhancing access to therapeutic interventions and activities.
• Increase the level and mix of staff on acute mental health inpatient wards, including improving access to peer support workers, psychologists, occupational therapists, social workers, housing experts and other relevant professionals during admission.
• Reduce avoidable long lengths of stay in adult acute mental health inpatient settings (including for people with a learning disability and autism), so that people are not staying in hospital any longer than necessary.
• Reduce the number of people with a learning disability and autistic people in mental health inpatient settings, so that by March 2024, there are no more than 30 adults with a learning disability and/or autism in an inpatient setting, per one million adults.
• Ensure that all inpatient care commissioned by the NHS meets the Learning Disability Improvement Standards.
• Further information on several of these commitments can be found in the NHS Mental Health Implementation Plan 2019/20 – 2023/24. Across the delivery of all of these commitments, consideration must be given to reducing the associated inequalities, involving people in decisions about their care and adapting interventions and activities to meet individual needs and preferences.