Dr Jon Van Niekerk
Chair, General Adult Faculty, Royal College of PsychiatristsGroup Medical Director, Cygnet Health Care
Too many people remain trapped in hospital not because they are unwell, but because the system cannot organise a safe route home. Partner content: Cygnet is a member of Curia’s Health, Care, and Life Sciences Research Group.
I am writing with two hats on.
One as Chair of the General Adult Faculty at the Royal College of Psychiatrists, representing thousands of psychiatrists working every day on acute wards and in community teams. The other as Group Medical Director of Cygnet Health Care, providing mental health and social care across around 160 services and more than 3,000 beds across the country.
From both perspectives, the same pattern keeps repeating. We have no shortage of national ambition. What we lack is a system that reliably translates that ambition into lived experience for patients.
What people encounter instead is a system defined by bottlenecks. They struggle to get into care when they are acutely unwell. Then, once treatment has worked, they struggle to get out again.
The implementation gap no one wants to own
Mental health policy in England is not short of vision. We have the Long Term Plan, the 10 Year Health Plan for England, manifesto commitments from a new government and a Mental Health Bill making its way through Parliament.
Yet clinicians see a widening implementation gap between what these documents promise and what happens on wards.
Delayed discharge is the clearest example. Recent analysis of NHS England data found that waiting for supported housing is now the single biggest recorded reason for delayed discharge from mental health hospitals, accounting for 19 per cent of all delayed discharge days.
That figure should stop us in our tracks.
It means a significant share of mental health beds are occupied not because people need hospital treatment, but because they have nowhere safe and supported to live.
“We are using hospital beds as a substitute for housing. That is neither humane nor efficient.”
This is not unique to mental health. Across the NHS, around one in seven hospital beds last winter were occupied by patients who were medically fit for discharge. But in mental health, the impact is sharper because recovery depends so heavily on stable housing and social support.
When shifting care went too far and too fast
The intention to move care from inpatient wards into the community was right. Few clinicians would argue otherwise. But in many areas, it has happened too far and too fast, without the community infrastructure being built first.
The persistence of inappropriate out of area placements tells the story. Despite a commitment to eliminate them several years ago, thousands of placement days still occur each quarter.
Local beds have been reduced. Community alternatives have not kept pace. The pressure has simply been displaced elsewhere.
The result is permanent crisis management. Ambulance crews and police searching for beds. Patients sent hundreds of miles from home. Community teams asked to manage extremely high levels of need without adequate housing or social care behind them.
This is not a failure of clinical care. It is a failure of system design.
You cannot fix flow without fixing housing
From a clinical perspective, the message is simple. You cannot fix flow through mental health services without fixing housing and step down care.
Evidence shows that effective support for social needs, including housing, income, and employment, reduces hospital admissions, shortens stays and improves long term outcomes.
Supported housing does not just help people live independently. It creates a safe, staffed environment where recovery can continue outside hospital.
The fact that supported housing now accounts for nearly a fifth of delayed discharge days in mental health hospitals simply puts numbers on what patients and clinicians have been saying for years.
“Step down and supported living are not optional extras. They are core clinical infrastructure.”
If we want to move from crisis management to recovery, transitional and step down services must be treated as essential parts of the pathway, not afterthoughts.
Commissioning across boundaries, not around them
Ask frontline teams what blocks discharge and you rarely hear about treatment. You hear about processes.
- The ward agrees someone is ready for discharge.
- The local authority panel meets in three weeks.
- The housing provider feels excluded from the clinical conversation.
These are not clinical failures. They are structural ones.
Integrated Care Boards are well placed to address this, but only if they are expected and enabled to work across organisational boundaries. That means pooling budgets with local authorities, jointly commissioning step down and housing pathways and bringing NHS, independent and voluntary providers into a single system rather than competing silos.
Some areas are already doing this well. Too often, success depends on a small number of committed individuals rather than a consistent national approach.
A national framework for jointly commissioned recovery pathways covering clinical care, housing and social support would make collaboration routine rather than exceptional.
Partners, not parallel systems
Independent and voluntary providers already deliver large parts of the mental health pathway under NHS commissioning. The question is not whether they should be involved. They already are.
The real question is whether all providers are aligned around the same recovery focused goals, standards, and outcomes.
If we treat every provider as part of one system, held to the same expectations and sharing the same data, capacity can be used more intelligently. Flexible step down, rehabilitation and specialist provision can relieve pressure quickly when local systems are under strain.
From owning risk to sharing responsibility
There is a deeper cultural issue beneath all of this.
In an overstretched system, conversations too often collapse into one question: who owns the risk?
Patients need us to ask something different. How do we share responsibility for recovery?
That means shared accountability between the NHS, local government, housing providers, and independent and voluntary services. It also means listening to what people tell us about the harm caused by being stuck in hospital or discharged into unsafe accommodation.
If we align national policy, local commissioning and frontline practice around that shared responsibility, mental health care does not have to remain stuck in crisis mode.
We already know what works. The challenge now is to build the system that lets it happen.
Find out more
Cygnet are members of Curia’s Health, Care, and Life Sciences Research Group. To find out more about the group, contact Partnerships Director, Ben McDermott at ben.mcdermott@chamberuk.com