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ENHANCED ONGOING SUPERVISION AND THE CODE OF PRACTICE UNDER MENTAL HEALTH ACT 1983

March 17, 2026
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For all parents and carers affected by barring/heavy ongoing restrictions, this blog is for you. It is regarded as totally unacceptable by the Care Minister (Stephen Kinnock however this is the reality for many in the UK. The ITN programme explored effects on some vulnerable person, parents and carers affected but the sad reality is that this situation is widespread, nationwide with many affected – thousands of vulnerable people are currently incarcerated on MH units for many years, not being properly assessed for physical health/neurological conditions such as FND, epilepsy, denied pathophysiological referrals/tests under neurology, endocrinology and immunology. Others in the community are likewise affected. Following a seizure for instance referral should be made according to Nice Guidelines NG217 within two weeks to see a specialist and there are specific guidelines for delirium. There are families whose vulnerable relative has been sent a long distance away, making visits difficult. It is wrong parents and carers are treated in such a dismissive manner, excluded from care meetings and any involvement by the NHS and certain care homes backed by Local Authorities. For those who complain the ultimate bullying is to deny contact or restrict contact without proper review, often for years on end. This has a widespread, devastating effect on families. On Mother’s Day my thoughts went out to all mothers who have no contact. It is a violation of human rights under Article 8 HRA to the vulnerable person and their families. I hope that something is done about this situation by the Government, especially with regard to neglect towards physical health and denial of pathophysiological tests to that person.

[Mother/Father’s Name]
[Address]
[Postcode]
[Email / Telephone]
[Date]

Clinical Management Team
[Hospital / Trust Name]
[Ward / Unit Name]
[Hospital Address]

Formal Request for Review of 2:1 Supervision and Written Reasons

Dear Clinical Management Team,

Re: 2:1 Supervision During Visits With My Relative (Son/Daughter)

I am writing as the mother of [Patient’s Name] regarding the requirement that two members of staff supervise my visits with my daughter.

While I understand that hospitals must manage risk appropriately, I am concerned that the requirement for two-to-one (2:1) supervision during my visits appears to have been imposed for some time without any clear explanation being provided to me, and without any indication that the restriction has been regularly reviewed.

As you will be aware, decisions affecting detained patients must comply with the Mental Health Act 1983and the guiding principles contained within the Mental Health Act Code of Practice.

The Code of Practice provides that:

·       Paragraphs 1.2 and 1.8 require that patients should only be subject to restrictions that are necessary and proportionate, and that the least restrictive option must be considered.

·       Paragraph 1.5 requires that any restrictive intervention must have a clear purpose and must not be imposed simply as a matter of routine.

·       Paragraph 1.7 emphasises the importance of respect, dignity and maintaining relationships with family members.

In addition, the continued imposition of 2:1 supervision during family visits interferes with the patient’s right to family life under Article 8 of the European Convention on Human Rights, which forms part of UK law through the Human Rights Act 1998. Any such interference must therefore be necessary, proportionate and capable of clear justification.

The presence of two staff members during visits makes it extremely difficult for my son/daughter and I to have normal private conversations and significantly affects our ability to maintain a meaningful family relationship.

If this restriction has not been regularly reviewed against current risk, it raises a concern that the requirement may be operating as a routine or blanket restriction, rather than a proportionate response to an identified risk.

Accordingly, I would be grateful if you could please provide the following information:

1.     The clinical rationale for imposing 2:1 supervision specifically during my visits.

2.     The dates and outcomes of all reviews of this restriction since it was first introduced.

3.     The risk assessment(s) currently relied upon to justify maintaining this level of supervision.

4.     Whether less restrictive arrangements for family visits have been considered.

5.     The date when this restriction will next be formally reviewed.

If this requirement has not been subject to regular and documented review, I am concerned that the continued imposition of 2:1 supervision during my visits may be disproportionate and therefore potentially unlawful.

For the avoidance of doubt, this letter should be treated as a formal request for written reasons for the restriction currently being imposed, and I would be grateful for a written response within 14 days.

If it would assist, I would also be happy to discuss the matter with the clinical team so that an arrangement can be agreed which appropriately balances safety with my son/daughter’s right to maintain a normal family relationship.

Yours sincerely,

[Mother’s Name]

HERE ARE THE GUIDELINES AND THOSE REGARDING SEIZURES AND DELIRIUM FOR ANYONE AFFECTED

NICE Guideline NG10 – Violence and Aggression: Short-Term Management in Mental Health Settings, and NHS Trust Enhanced Observation Policies.

Risk assessments must be regularly reviewed

The guideline requires continuous review of risk management plans:

Risk assessments and risk management plans should be regularly reviewed, and care plans must be based on accurate and thorough risk assessments.

This principle directly affects enhanced observation levels such as:

· 1:1 observation

· 2:1 observation

· constant observation

If the observation level is not being reviewed regularly, it may breach national clinical guidance.

How NG10 Connects to 2:1 Supervision

Although NG10 does not specify the exact term “2:1 supervision”, it governs the restrictive interventions and observation frameworks that hospitals rely on when implementing such measures.

Typical NHS observation levels include:

Observation level Description

General

observation periodic checks

Intermittent

observation checks at set intervals

Within eyesight continuous observation

Within arm’s

length very high-risk monitoring

2:1 observation two staff members observing the patient

Under NICE and NHS policy:

· the clinical justification must be documented

· the observation must be reviewed frequently

· it must remain proportionate and justified by evidence

PRE-ACTION PROTOCOL LETTER TO FOLLOW UP IF NO RESPONSE

[Your Name] [Your Address] [Postcode] [Email / Telephone]

Date: [Insert Date]

BY EMAIL AND RECORDED DELIVERY

The Responsible Clinician The Ward Manager The Mental Health Act Office [Name of NHS Trust] [Hospital Address]

LETTER BEFORE ACTION – INTENDED COURT OF PROTECTION PROCEEDINGS

Re: [Patient’s Full Name / DOB] – Unlawful Contact Restrictions and 2:1 Supervision

Dear Sir/Madam,

I write formally concerning the ongoing restrictions placed upon my contact with [Patient’s Name], who is currently receiving care at [Ward/Hospital] under the responsibility of [NHS Trust].

This letter constitutes a formal Letter Before Action and should be treated as notice that, unless the matters set out below are addressed urgently, I intend to issue proceedings in the Court of Protection without further notice.

Unlawful Interference With Family Life

The Trust is currently restricting or controlling my contact with [Patient’s Name], apparently on the basis of the patient’s 2:1 supervision / enhanced observation level.

These restrictions amount to a serious interference with family life, protected under the Human Rights Act 1998 – Article 8 (Right to respect for family life)

Any interference with Article 8 rights must be lawful, necessary, proportionate and supported by evidence of risk

At present, the Trust has failed to demonstrate that these requirements are satisfied.

Statutory Duties Under the Mental Capacity Act

If the patient lacks capacity to determine contact arrangements, the Trust is under a statutory duty to act in accordance with the Mental Capacity Act 2005.

In particular:

· Section 4 requires all decisions to be taken in the person’s best interests, including proper consideration of family relationships.

· Sections 15 and 16 confer jurisdiction on the Court of Protection to determine issues relating to welfare, contact, and care arrangements.

Where contact between a patient and family member is restricted without lawful justification, the Court may make binding welfare orders regulating contact and directing the NHS Trust to amend its care arrangements.

Observation Policies and 2:1 Supervision

The Trust appears to be relying on the patient’s 2:1 supervision level as justification for the present restrictions.

Enhanced observation measures of this type are governed by NICE Guideline NG10 – Violence and Aggression: Short-Term Management in Mental Health Settings, and NHS Trust Enhanced Observation Policies.

These policies require that:

· Enhanced observations must be risk-based and individually justified

· Observation levels must be subject to regular clinical review

· The least restrictive principle must be applied

· Restrictions on family contact must be supported by a specific risk assessment relating to that contact

Enhanced observation does not provide lawful authority for blanket restrictions on family contact.

Serious Procedural Concerns

Despite repeated requests, the Trust has failed to provide:

· the risk assessment said to justify restricting family contact

· the care plan provisions governing such restrictions

· observation review records relating to the patient’s 2:1 supervision

· any evidence demonstrating that less restrictive alternatives have been considered

If these documents do not exist, the current restrictions may be unlawful and incompatible with both the Mental Capacity Act and Article 8 rights.

Required Disclosure

In order to avoid litigation, the Trust is requested to provide the following within 14 days:

1. The patient’s current care plan.

2. All risk assessments relating to family contact.

3. All observation level review records relating to the patient’s 2:1 supervision.

4. The policy or clinical basis relied upon to restrict family contact.

5. Confirmation of the schedule and procedure for reviewing observation levels and associated restrictions.

Intended Court of Protection Application

If the above information is not provided, or if the current restrictions remain in place without lawful justification, I will issue proceedings in the Court of Protection seeking:

· A declaration regarding the patient’s capacity to decide contact

· A declaration that the current restrictions are unlawful and disproportionate

· A welfare order regulating contact between the patient and family members

· Directions requiring the Trust to amend the care plan and observation arrangements

· Any further relief the Court considers appropriate

The Court of Protection has the power to make binding orders requiring NHS Trusts to alter care arrangements where they unlawfully interfere with family life.

Opportunity to Resolve Without Litigation

Litigation can still be avoided if the Trust:

· reviews the current restrictions urgently,

· provides the documentation requested above, and

· confirms that the patient’s contact with family will be managed in accordance with statutory duties and the least restrictive principle.

If no satisfactory response is received within 14 days, proceedings will be commenced without further notice.

Yours faithfully,

[Your Name]

NICE NG217 Guideline on Seizures

1. Urgent referral after first seizure or recurrence

NG217 1.1.1 – First suspected seizure

“Refer children, young people and adults urgently (for an appointment within 2 weeks) for an assessment after a first suspected seizure”
— NICE NG217¹, Recommendation 1.1.1. 

This uses urgent referral, defined by NICE as an appointment within 2 weeks, for anyone after a suspected seizure.

NG217 1.1.2 – Seizure recurrence

“Refer children, young people and adults urgently (for an appointment within 2 weeks) for an assessment if they have a seizure recurrence after a period of remission.”
— NICE NG217¹, Recommendation 1.1.2. 

A recurrence after remission is repeated and unexplained, and under NICE this is explicitly urgent — same timeframe as first seizure.

2. Implication for repeated unexplained seizures

Even though NG217 does not use those exact words (“repeated unexplained seizures”) in a standalone recommendation, the guidance is clear from these linked recommendations:

  • Any recurrence (repeated seizure) after a seizure-free period triggers the same urgent referral timing as a first seizure.
    → This means 2 weeks maximum to specialist assessment. 
  • The guideline does not recommend routine or non-urgent pathways for recurrent or potentially multiple unexplained seizures in adults or children. 

3. Investigations are recommended promptly too

While NG217 separates referral timing (urgent within 2 weeks) from investigations, it also states:

EEG timing

“…if an EEG is requested after a first seizure, perform it as soon as possible (ideally within 72 hours after the seizure).”
— NICE NG217, EEG section. 

This supports early investigation following urgent specialist review.

Neuroimaging

“Offer brain neuroimaging tests if an underlying structural cause is suspected…”
— NICE NG217. 

This reinforces that after urgent specialist assessment, relevant investigations should not be unreasonably delayed when clinically indicated.

SituationNICE RecommendationTimeframe
First suspected seizureUrgent specialist referral (1.1.1)Within 2 weeks
Repeat seizure after remission (i.e., repeated unexplained)Urgent specialist referral (1.1.2)Within 2 weeks
EEG after suspected seizureEarly investigationIdeally within 72 hrs
Neuroimaging if neededPrompt test as indicatedNo specified fixed max—but not deferred

Key takeaway from NICE wording

NICE NG217 does not permit prolonged routine delays for repeated unexplained seizures. According to its urgent referral recommendations (1.1.1 & 1.1.2):

A recurrence or repeated unexplained seizure merits the same urgent (2-week) referral as a first seizure. 

Follow-up investigations (EEG, imaging) should then be arranged as soon as clinically appropriate, not deferred indefinitely. 

NICE GUIDELINES  CG103  DELIRIUM

Before the referral meeting and most certainly before the scan a patient needs to be properly rested to avoid physiological confounders.  

Good clinical practice in cognitive and neurological assessment requires that potentially reversible causes of impaired cognition are identified and corrected before diagnostic conclusions are drawn.

Under NICE guideline CG103 (Delirium: prevention, diagnosis and management), clinicians must assess for acute physiological contributors to confusion, including dehydration, infection, hypoxia, hypoglycaemia, metabolic disturbance, and medication effects. The guideline emphasises that delirium is common, serious, and frequently reversible, and that failure to detect underlying medical causes risks misdiagnosis.

Accordingly, cognitive assessment should occur only when the patient is medically stable. Good practice therefore includes:

  • Excluding delirium and acute illness
  • Correcting dehydration and metabolic abnormalities. (nourishment, breakfast to avoid hypoglycaemia)
  • Reviewing medications and substances
  • Managing pain and sleep disturbance (a proper nights sleep before to avoid confusion due to tiredness) 
  • Ensuring appropriate sensory aids and a suitable testing environment

While CG103 does not explicitly state that a patient must be “relaxed and properly nourished,” its requirements to identify and treat reversible contributors to confusion implicitly support optimisation of physiological and environmental conditions prior to assessment.

In summary, consistent with CG103, cognitive evaluation should be undertaken under conditions that minimise reversible confounders to ensure diagnostic validity and patient safety.

COUNCIL & TRUST FAILINGS IN: Care planning, Continuity /Consistency of Care, Capacity in Recovery Services, and Responsiveness to Changing Needs.

November 17, 2025
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Evidence of New / Escalating Criticism of Lincolnshire Adult Social Care

Ombudsman / Care Act Failures

A recent (April 2025) LGO decision (ref 24-003-962) found fault in how LCC (via Lincolnshire Partnership NHS Trust, acting for LCC) handled a Care Act assessment and care plan for a person with mental and physical health needs. Specifically: no advocate was involved despite communication difficulties, care was inconsistent, and there was poor communication / information-sharing — this caused distress. Local Government Ombudsman

Another case (Centre for Adults’ Social Care report, June 2025) describes a woman with complex mental health needs whose move into the county triggered fragmented / inadequate support. LCC (via its partner trust) failed to provide consistent care, arranging too few hours vs her assessed need, and she suffered distress, hospital admissions, and isolation. cascaidr.org.uk

A separate Ombudsman ruling (July 2025) relates to transition from children’s to adult services. LCC made “errors in care package decisions and communications” for a young adult with disabilities (including transport for day-centre attendance), causing her to miss care. cascaidr.org.uk+1

Healthwatch Lincolnshire Feedback

The Healthwatch Lincolnshire report (2025) includes a case (Feb 2025) of an adult social care user whose health needs were compromised because of lack of proper care provision. According to the report, the person is a wheelchair user and needs increased care post-operation, but LCC could not guarantee provision for that increased care, leading to the cancellation of a surgery. Healthwatch Data

While this is not explicitly “mental health care,” it shows stress / risk in how adult social care assesses and responds to changing care-need demands — including when health interventions (surgery) would make care needs temporarily more intense.

Local Media / Policy

Lincolnshire World reported very recently (Oct 2025) that LCC officials are considering reducing the number of “active recovery beds” (mental-health-related step-down beds) from 29 to 24. That’s a significant signal: reducing capacity in part of the mental health recovery system could be seen as cutting back or deprioritising mental health care for adults. LincolnshireWorld

Complaint Statistics

In its 2024–2025 complaints report, LCC notes that 23 complaints from that year were escalated to the LGSCO about adult care. Lincolnshire County Council

While not all these will be about mental health, it suggests a non-trivial volume of serious complaints in the adult care sphere.

Interpretation & Assessment

The Ombudsman findings are the strongest concrete evidence: there are real cases where LCC has failed to provide or plan care properly for people with mental health or complex needs. These are not isolated paperwork mistakes, they have caused distress and had a material negative impact.

The Healthwatch case indicates that some people struggle to get social care to respond when their health needs (which may interact with mental health) change. That could suggest capacity / resource problems in LCC’s adult social care provision.

The proposal to reduce active recovery beds is worrying: if implemented, it could worsen recovery pathways for people needing step-down mental health care. That could be a policy direction that reduces service rather than expands it.

However, the CQC’s most recent (pilot) assessment of LCC adult social care is still “Good”, which means from a regulator’s perspective, the overall adult social care system is functioning reasonably well (though not without room for improvement, especially in certain pathways). Lincolnshire County Council+2Care Quality Commission+2

There is new and escalating criticism of LCC’s mental-health-related adult care: through Ombudsman decisions, Healthwatch reports, and potentially in policy (bed reductions).

The criticisms are not wholesale systemic collapse, but they do raise serious concerns about how well LCC is meeting the needs of vulnerable adults — particularly those with complex mental health or changing care needs.

Some of the key pressure points: assessment and care planning, continuity / consistency of care, capacity in recovery services, and responsiveness to changing needs.

Briefing Summary: Criticisms of LCC Adult Mental Health Care (2023–2025)

1. Financial & Demand Pressures

LCC’s 2024/25 financial performance review reports a significant overspend in mental health adult care:

Community supported living (for working-age / mental health clients) overspent by £3.2 million, of which £1,060,000 relates to “Growth in demand for DoLS / LPS” (Liberty Protection Safeguards) due to a much higher-than-expected increase in client numbers (94 new clients vs 25) planned). lincolnshire.moderngov.co.uk+2lincolnshire.moderngov.co.uk+2

Long-term residential mental health care also saw growth: 27 new clients, resulting in a £0.408 million overspend. lincolnshire.moderngov.co.uk+1

Short-term care (mental health) clients exceeded budgeted numbers, adding further financial pressure. lincolnshire.moderngov.co.uk+1

The budget for 2025/26 continues to forecast rising demand in mental health: LCC recognizes a 3–6% annual growth in working-age / mental health service demand. lincolnshire.moderngov.co.uk

In its executive meeting (Aug 2025), the Overview & Scrutiny Management Board flagged this as a “volatile and risk-based” budget area, with ongoing close monitoring. lincolnshire.moderngov.co.uk

Implication: LCC may be under-estimating both the scale and pace of demand growth for mental health care, risking repeated overspends and service strain.

2. Service Reduction Controversies – Active Recovery Beds

Local media (LincolnshireWorld) report that LCC is proposing to reduce the number of Active Recovery Beds (ARBs) from 29 to 24. LincolnshireWorld

These beds are used for people stepping down from hospital but not yet ready to return home, reducing them could limit “step-down” capacity. LincsOnline+1

The Council argues the reduction aligns with “presenting demand” and will improve occupancy (from ~70% to ~90%). LincolnshireWorld

However, some councillors have expressed concern: e.g., whether this reduction under-provides in the face of broader NHS / social care pressures. LincolnshireWorld+1

Implication: The proposed cut could undermine recovery capacity; critics worry demand may outstrip reduced supply, especially as patients leave hospital.

Ombudsman Findings – Assessment & Care Planning Failures

In LGO decision 24-003-962 (April 2025), the Ombudsman upheld a complaint against LCC:

LCC (via its partner, Lincolnshire Partnership NHS Trust) failed to provide reasonable adjustments in a Care Act assessment despite the complainant’s mental and physical health issues. Local Government Ombudsman

The decision-making was inconsistent: carers were not familiar with her, there was inadequate handover, and no advocate was involved even when needed. Local Government Ombudsman

The Council also made housing decisions (moving the person) that the Ombudsman found unsuitable. Local Government Ombudsman As a remedy: LCC must apologise and pay a sum to acknowledge the injustice caused. Local Government Ombudsman

A separate Cascaidr analysis (July 2025) highlights another case: LCC failed to properly manage a care package for a person with mental health and possibly autistic traits. Adult Social Care Centre

The complaint noted that LCC did not properly assess the person’s capacity or share information with providers, leaving her without adequate support. Adult Social Care Centre

The analysis argues that LCC’s assessment systems / legal understanding may be weak in dealing with complex, capacity-fluctuating mental health cases. Adult Social Care Centre

Another Cascaidr / Ombudsman case (Sept 2025): poor management of transition from children’s to adult services for a young woman with disabilities (including mental health / supportive needs). Adult Social Care Centre

The Council initially promised transport + day-centre attendance but later withdrew transport without confirming that a closer centre could meet her needs, resulting in missed care. Adult Social Care Centre

The Ombudsman found LCC at fault: decisions were made without fully checking alternatives; communication was confusing; and there was procedural failure in its authorisation processes. Adult Social Care Centre

The Council was required to apologise and pay a symbolic amount, and to remind staff about proper internal authorisation procedures. Adult Social Care Centre

Implication: There appear to be systemic weaknesses in LCC’s assessment, planning, and communication processes especially for people with complex mental health needs or transitioning from children’s services. This raises risk of unmet need, distress, and legal non-compliance.

Local Advocacy / Healthwatch Voice

Healthwatch Lincolnshire’s 2024/25 Annual Report shows increasing engagement, but also highlights challenges: while not all issues are mental health–specific, many concern social care access, capacity, and unmet needs. healthwatchlincolnshire.co.uk

In the 2024–25 interim work plan, Healthwatch identified “influencing decision-makers” and “addressing underrepresented groups” as key priorities, suggesting they are pushing for more responsive, inclusive care provision. healthwatchlincolnshire.co.uk

Local media commentary (LincolnshireWorld) also notes LCC acknowledging rising complexity in mental health care packages and growing costs:

“a major contributor to cost pressures … an increase in demand and complexity of mental health services.” LincolnshireWorld

Implication: Local citizen-led organisations are raising the alarm about escalating demand, growing complexity, and pressures on mental health adult care — suggesting these are not just financial issues but affect quality and accessibility.

Strategic & Systemic Risks

During a Council Executive meeting (July 2025), a councillor (Steve Clegg) explicitly questioned LCC’s mental health community support overspend. The Executive Director (Adult Care) acknowledged demand is rising “faster than elsewhere” and hinted at concerns over the quality of existing service delivery. Open Council Network

LCC’s written evidence to Parliament (recent submission) also warns that demand for adult mental health care is exceeding previous forecasts, putting “increasingly strained” pressure on the system. UK Parliament Committees

Implication: The financial and service pressures are not short-term or one-off: there’s a real risk that demand continues to outpace LCC’s capacity, potentially degrading care quality or forcing tough decisions (like bed cuts).

Overall Summary

Demand is rising fast: LCC is seeing more working-age / mental health adult clients than budgeted for, driving large cost overruns.

Service capacity is under threat: Proposed reductions in Active Recovery Beds raise concerns about recovery pathways.

Professional standards are being questioned: Ombudsman decisions show LCC sometimes fails in assessments, support planning, and legal duties, especially for those with complex, fluctuating mental health needs.

Local voices (Healthwatch, Councillors) are pushing back: There is growing unease about how LCC is managing this demand, both financially and in terms of service delivery.

Strategic risk is real: Unless LCC adapts, by increasing capacity, improving assessment processes, and planning strategically — there is a danger that its mental health adult care provision will become unsustainable.

A separate Cascaidr analysis (July 2025) highlights another case: LCC failed to properly manage a care package for a person with mental health and possibly autistic traits. Adult Social Care Centre

The complaint noted that LCC did not properly assess the person’s capacity or share information with providers, leaving her without adequate support. Adult Social Care Centre

The analysis argues that LCC’s assessment systems / legal understanding may be weak in dealing with complex, capacity‑fluctuating mental health cases. Adult Social Care Centre

The Care Act 2014 requires councils to assess any adult who appears to need care and support, regardless of financial circumstances, and to involve the individual and any carer or anyone else they wish to be involved. Assessments must be timely, involve the person, and consider their wellbeing and desired outcomes. Care and support plans must be co-produced, include a personal budget, and be responsive to changing needs. 

When a person moves between council areas, there are statutory duties to ensure continuity of care (section 37), but they do depend on the destination council knowing that the person is on their way. 

Councils must also consider reasonable adjustments for communication and mental health needs, and ensure advocacy is provided where it is triggered by the concept of the person’s substantial difficulty engaging in the Care Act processes of assessment, care planning or revision (regardless of having a willing relative) without one being appointed. 

The failure to provide adequate care and support, or to arrange advocacy, is a breach of statutory duty.  It renders the assessment invalid, in community care and public law and that has been the case since the Haringey judgment in 2015.

DELAYED DISCHARGE

October 18, 2025
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A delayed discharge case is when a patient is medically ready to leave a hospital but remains there for non-medical reasons. The delay can be caused by factors like a lack of available social care, insufficient community care packages, or issues with the hospital’s own processes. These delays are a major concern as they reduce hospital bed capacity, potentially leading to poorer patient outcomes and increased healthcare costs. 

Delayed discharges: why it’s hard to say how many are due to social care capacity

Authors

Here’s a multiple-choice quiz. What percentage of delayed discharges from hospital are caused by lack of adult social care capacity? Is it:

a) Most of them

b) 50%

c) 12%

d) There’s no way of knowing for certain.

The answer is d): we just don’t know. You get half a point if you said c) because 12% is the most we can definitely attribute to lack of social care capacity from the publicly available data. However, you’d be forgiven for thinking it was b) or even a) if you simply read the media coverage. In December, the Royal College of Nursing was quoted as saying that there was ‘barely a spare bed’ left in NHS hospitals due to a lack of capacity in social care; while in January, the NHS Confederation was reported as saying that 20% of NHS bed capacity was taken up by patients who were only there because they ‘cannot get a suitable care package’.

“Yet we don’t know the number – because, with the best of intentions, we chose to stop asking.”

Yet we don’t know the number – because, with the best of intentions, we chose to stop asking. In 2020, NHS England stopped separating out reasons for delay between health and social care. The reasoning, based on discussions with health and care organisations, was that delays were often complex, and instead of allocating them to one or other partner, systems should take responsibility, rather than individual sectors.

The most recent data recording, introduced in May 2024, requires discharge hubs (or sometimes wards) to classify the causes of delay into one of five categories:

  1. Hospital process (issues within the hospital’s control, such as medication or transport)
  2. Wellbeing concerns (issues outside the hospital’s control, for example where a family has doubts about a patient’s readiness for discharge)
  3. Care transfer hub process (most commonly where the patient’s destination has not yet been decided)
  4. Interface process (typically where transfer plans are underway but have not yet been completed)
  5. Capacity (where the service needed by the patient is not yet available).

Except for hospital process, all these categories include delays that are due to both the NHS and social care. For patients with stays of at least 14 days (the only publicly available measure), on average 9,309 people were delayed each day in March 2025. Of these, 3,203 delays were ascribed to ‘capacity’, followed by interface process (2,639), hospital process (1,754), care transfer hub process (1,200) and wellbeing concerns (514).

If we focus on those 3,203 capacity delays – because lack of social care capacity is often cited as a key cause of delayed discharges – the single largest reason (966 people delayed) is lack of ‘bed-based rehabilitation, reablement or recovery services’.

https://www.landmarkchambers.co.uk/news-and-cases/blog/health-and-social-care-law/delayed-transfer-of-care-leads-to-100k-legal-bill-for-an-icb

This covers a wide range of health and care services, some of which are commissioned by NHS trusts, some by local authorities and some jointly. Even discharge hubs would not be able to allocate them to ‘the NHS’ or ‘social care’. The same applies to ‘home-based rehabilitation, reablement or recovery services’ (502 people delayed), which again cannot be split neatly into social care or NHS.

In fact, only three of the sub-categories – lack of home-based social care services (257), lack of residential or nursing care (762), and people waiting for restart of existing social care services (63) – are solely attributable to social care. But these account for only 34% (1,082) of the 3,203 total ‘capacity’ delays and only 12% of the total 9,309 delayed patients. The real figure for social care delays will be higher because it will include some of the bed-based and home-based rehabilitation and reablement delays but is not counted.

“Yet the NHS and social care are two distinct systems, funded differently, usually commissioned differently and often with different immediate concerns.”

Author:

Into that data vacuum has emerged a range of guesses and estimates, some more authoritative than others. For example, in March NHS England told the House of Commons Health and Social Care Committee that around a fifth of bed days (note that this is a different measure to the publicly available one) lost to delayed discharge ‘are for individuals accessing adult social care packages on discharge’.

In an ideal world, it might not matter. Local systems would be working together to identify problems, avoiding blame and finding joint solutions. Perhaps most are already. Yet the NHS and social care are two distinct systems, funded differently, usually commissioned differently and often with different immediate concerns. On the NHS side, there is intense media and public concern about hospital capacity, A&E waits and ‘corridor care’. On the social care side, there is a longstanding grievance about lack of funding.

In these circumstances, it has sometimes suited both sides for lack of social care capacity to be seen as the key cause of hospital discharge delays. It allows social care to make the case for more money and deflects attention from the NHS causes of delay. This is why the headlines are tolerated, sometimes encouraged.

“It allows social care to make the case for more money and deflects attention from the NHS causes of delay. This is why the headlines are tolerated, sometimes encouraged. ”

Author:

Yet it can still rankle within social care if it is held largely responsible for a problem to which it is, in fact, only a minority contributor. There is a long and inglorious tradition of blaming social care for hospital discharge delays.

There is also irritation about the word ‘capacity’: there is plenty of capacity in care homes, says the sector (occupancy has still not quite returned to pre-pandemic level); the issue is that commissioners (in both the NHS and local authorities) are not sufficiently well organised and are unable or unwilling to pay a fair price for it.

In this difficult environment, avoiding a blame game on hospital discharge was always going to be ambitious. It’s proved to be that – and more. Time to accept reality and publish a credible official estimate of the respective responsibilities for delayed discharge of health and social care.

Further reading

MEDICATION, IMPACT and PATHOLOGICAL TESTS

December 26, 2023
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How Medicine Works and When It Doesn’t: Learning Who to Trust to Get and Stay Healthy Hardcover – 24 Jan. 2023 
by  F Perry Wilson  (Author)
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Blending personal anecdotes with hard science, an accomplished physician, researcher, and science communicator gives you the tools to avoid medical misinformation and take control of your health​ “A brilliant step toward patients and physicians alike reclaiming a sense of confidence in a system that often feels overwhelming and mismanaged” (Gabby Bernstein, #1 New York Times bestselling author of The Universe Has Your Back).

We live in an age of medical miracles. Never in the history of humankind has so much talent and energy been harnessed to cure disease. So why does it feel like it’s getting harder to live our healthiest lives? Why does it seem like “experts” can’t agree on anything, and why do our interactions with medical professionals feel less personal, less honest, and less impactful than ever? 

Through stories from his own practice and historical case studies, Dr. F. Perry Wilson, a physician and researcher from the Yale School of Medicine, explains how and why the doctor-patient relationship has eroded in recent years and illuminates how profit-driven companies–from big Pharma to healthcare corporations–have corrupted what should have been medicine’s golden age. By clarifying the realities of the medical field today, Dr. Wilson gives readers the tools they need to make informed decisions, from evaluating the validity of medical information online to helping caregivers advocate for their loved ones, in the doctor’s office and with the insurance company. 

Dr. Wilson wants readers to understand medicine and medical science the way he does: as an imperfect and often frustrating field, but still the best option for getting well. To restore trust between patients, doctors, medicine, and science, we need to be honest, we need to know how to spot misinformation, and we need to avoid letting skepticism ferment into cynicism. For it is only by redefining what “good.

Maria Cristina Patru1 and David H. Reser 2*
1Department of Psychiatry, Hôpitaux Universitaires de Genève, Geneve Switzerland, 2 Department of Physiology, Monash
University, Melbourne, Australia
Edited by:
Bernat Kocsis,
Harvard Medical School, USA
Reviewed by:
Sabina Berretta,
McLean Hospital, USA
Ami Citri,
The Hebrew University, Israel
*Correspondence:
David Reser
david.reser@monash.edu
Specialty section:
This article was submitted to
Schizophrenia,
a section of the journal
Frontiers in Psychiatry
Received: 23 July 2015
Accepted: 26 October 2015
Published: 09 November 2015
Citation:
Patru MC and Reser DH (2015)
A New Perspective on Delusional
States – Evidence for
Claustrum Involvement.
Front. Psychiatry 6:158.
doi: 10.3389/fpsyt.2015.00158

“Delusions are a hallmark positive symptom of schizophrenia, although they are also
associated with a wide variety of other psychiatric and neurological disorders.

The heterogeneity of clinical presentation and underlying disease, along with a lack of experimental
animal models, make delusions exceptionally difficult to study in isolation, either in
schizophrenia or other diseases. To date, no detailed studies have focused specifically on
the neural mechanisms of delusion, although some studies have reported characteristic
activation of specific brain areas or networks associated with them. Here, we present a
novel hypothesis and extant supporting evidence implicating the claustrum, a relatively
poorly understood forebrain nucleus, as a potential common center for delusional states.”

Elizabeth’s scan shows a lesion in precisely that area of the brain (marked in blue with red arrow) which needs to be properly identified.  See also page three of the PDF paper.

This is directly in the meso-limbic pathway and is associated with delusional behaviour in what some people are still calling schizophrenia.   

If you look at page 3 of this paper you will see the brain pictured in coronal, sagittal and horizontal view and the arrows triangulate to where the image/lesion appears in the right hemisphere of her brain on the scan at position 7/24 of the coronal image from the MRI.   

This urgently needs looking at by a neurologist and reference needs to be made to this paper.

Whilst commencing to write this blog Elizabeth has just called. She said yesterday that she spent six hours in seclusion whilst being rapidly tranquilised on Xmas Day.

Despite this, Elizabeth did not sound too bad during her supervised phone call. She spoke of escape. By this she clearly said that she escapes in her mind ie dissociation - this is a sign of PTSD for which Elizabeth has never had any treatment for under NHS. Also she has never had underlying pathological tests until I have had to point out the results of the private scan and observations by independent specialists and experts.

With an appointment on the 3 January with a Neurologist that had previously been flatly refused I really do hope that once and for all her whole treatment will be reviewed based upon the findings which clearly indicate the above.

It has been a nightmare to even try to get certain doctors to acknowledge let alone look into something that has been clearly stated in the files going back to 2009. This could all indicate why the treatment has not worked for so many years.

I am very unhappy at the current punishment of having the phone taken away for a trial period. This has already been tried before. I see this as bullying aimed directly at me because I am the one being blamed for the ‘episodes’ that look like fits never seen before even though many of these take place when I am not around. The necessity the MDT believes to be right is completely wrong and has not achieved anything before at Ash Villa except mistrust and upset and nothing is being done in line with the law and correct procedures and now these same restrictions incorporating Xmas is yet again being “tried”.

I hope to put an end to this bullying once and for all as that is how we see it. I am not going to sit back and do nothing whilst this punishment continues for years and years on end as I believe the whole environment of a noisy acute ward to be completely wrong and the whole approach of punishment also.

This is punishment not care. Punishment to stop my daughter from going out to the shop in the hospital grounds, punishment from stopping her listening to her music on her phone by keeping it locked away. What is this achieving?  NOTHING but resentment an mistrust and this has been ongoing for one month now with no end in sight.  

“Treat people as individuals and uphold their dignity and to do this you must treat people with kindness, respect and compassion and respect and uphold people’s human rights, challenge poor practice and discriminatory attitudes and behaviour relating to their care.

“Act with honesty and integrity at all times, treating people fairly without discrimination, bullying or harassment.  Keep to the laws of the country in which you are practising. Never allow someone’s complaint to affect the care that is provided to them.”