Not being able to leave the ward was overwhelming for Hannah*.
“One of the most important things when I've been in hospital before is being able to go home and being able to test out being back in my flat. Without that it was very difficult to readjust to going home.”
Hannah spent two months in hospital detained under the Mental Health Act in June and July last year, in the middle of a global pandemic.
While she was there, she could not leave the hospital grounds for longer than half an hour.
“How long and where you were actually allowed to go was more restricted because of the pandemic. I suppose to stop the spread of people going too far away,” Hannah says.
Being able to leave the hospital is an important part of a patient’s recovery journey, says Jessica Slingsby, Modern Matron for Adult Mental Health Inpatient Services in Humber Teaching NHS Foundation Trust.
“People do need to recover and a part of that is assessing people in their home environment.”
Hospital leave is time away from the hospital with the intention of returning to the ward. It can be leaving the ward for a short time, going home or doing some other activity such as going shopping.
For patients detained under the Mental Health Act, the responsible clinician decides if a patient is allowed to go on leave, also called Section 17 leave or leave of absence. Sometimes patients are required to go with a member of staff which is called escorted leave.
Opposed to that, informal patients, who are in hospital voluntarily, are free to leave the ward whenever they want to but should let staff know.
The Care Quality Commission (CQC) stressed the importance of leave, especially for detained patients, in their report Monitoring the Mental Health Act in 2019/20: The Mental Health Act in the coronavirus (COVID-19) pandemic:
“For most detained patients, leave is not simply an opportunity to spend time off the ward, but also a step towards eventual discharge from detention and a key part of rehabilitation.”
Covid on the wards: restrictions and safety measures
Like Hannah, patients on mental health wards in England were impacted by the introduction of Covid safety measures.
Early on, NHS England and Improvement have issued guidance for Mental Health, Learning Disabilities and Autism Services on responding to COVID-19 and supporting people of all ages during the pandemic.
In the latter, published in May 2020, they refer to the possibility of increased use of blanket restrictions to maintain safe care where staffing levels are significantly impacted by Covid-19.
However, they state that this should not impact Section 17 Leave which is considered an important part of preparing patients for their discharge from hospital.
The report said:
“Section 17 leave should still be made available to individuals where this is appropriate while giving due consideration to the requirements on social distancing and the need to reduce risk of transmitting COVID-19.”
Similarly, the Royal College of Nursing (RCN) has developed guidance for inpatient mental health staff in which they say that leave from the ward should be maintained.
“Patient leave from the ward, either escorted or unescorted, will require additional risk assessment depending on their exposure to symptoms. Where possible, leave and time off the ward should be maintained. If it is not possible this should be clearly communicated to the patient including the process for review.“
Hospital leave falling when the pandemic hit
For the purpose of this investigation, we have sent Freedom of Information requests to 51 NHS mental health trusts in England asking for the number of leave events that have been granted to patients each month.
35 trusts responded in time and provided data. However, due to the way trusts store the data, there were some inconsistencies. For accuracy, only figures from 23 trusts were used.
The data reveals that, across all trusts, the patients' hospital leave has been significantly impacted by the pandemic with monthly instances of granted leave dropping when the pandemic hit last year.
The average across all trusts was a decrease of 62 per cent.
When the pandemic hit, trusts were told to discharge patients when possible to free up bed capacity.
Click on the bars to find out how the drop in inpatients compares to the drop in leave.
In two of the trusts, the number of inpatients even increased in the same period.
The kind of leave the trusts included in the data differs.
In four trusts, the figures also include leave during the day with a length of less than a day.
About the data: 35 trusts provided data on hospital leave, out of 51 that received the request. The requests showed that trusts record leave data differently. Data from 10 trusts was excluded because they either provided the number of leave days instead of instances of leave or the number of patients who had at least one day of leave per month. Two trusts were only able to report on yearly figures.
Figures include home leave and leave of absence, although not all trusts were able to provide this breakdown and provided the total number of leaves instead. Figures show instances of leave that have started each month and can include the same patient more than once if they got leave repeatedly.
Patients unable to leave the ward
When Hannah was detained, she was first sent to another hospital out of her area because no beds were available in her local trust.
There, she did not get any leave at all. During her one-week-long stay, she could not leave the ward — not even for a walk.
“It made me feel incredibly frustrated,” Hannah says
“It’s so overwhelming being on the wards and wanting to get off them, just for a break from that environment.”
After one week, she got transferred to a unit closer to her home. There, she did get some leave, but, compared to when she was inpatient before, it was less frequent and less regular.
Especially, if leave was escorted, which means with a member of staff, it was dependent on the availability of staff, Hannah says: “It was about there being enough staff on the ward to be able to take you. If people were off sick and they were struggling with staff, then sometimes even if you were written up for leave, it was difficult to take leave.”
Mad Covid is a service user led group that was formed in March 2020 in response to the COVID-19 pandemic. They aim to bring together the voices of people with lived experience to influence change in real time. In November 2020, they published a series of recommendations for mental health services during the COVID-19 pandemic.
In their report, a service user describes their experiences with leave when they were admitted to hospital during the pandemic:
“We’re in lockdown, so there's no leave and no visitors and haven’t been for four weeks now. That’s had a huge negative impact because I kind of just want to see my mum. Also not being able to go on leave means not being able to go for a walk. I'm sleeping a lot worse because I’m not getting any exercise, and it’s also going to be very difficult getting discharged when I haven't been outside in four weeks.”
The Royal College of Psychiatrists says it is aware of substantial delays to the granting of leave that can have a detrimental effect on patients’ care and deprive them of the right to see their loved ones.
A spokesperson said:
“Leave from hospital is an important part of a patient’s care, promoting recovery and allowing patients to retain connections with their families and communities.“It is also a time when risks to the patient must be monitored, as well as potential difficulties faced by carers and is therefore important that hospital leave is based on sound clinical assessments and engagement with patients.”
What trusts are saying
A spokesperson from Southern Health NHS Foundation Trust said that, as part of their response to minimise the risks of the COVID-19 pandemic, they took "the difficult decision to restrict patient leave and visiting to ensure patients and staff could remain as safe as possible".
As an alternative to leave, the wards were encouraged to make full use of outdoor spaces such as gardens and courtyards as well as introduce extra activities.
"Due to the level of the virus in the community, we are re-introducing leave in-line with patient recovery plans. This means patients who need to take leave in order to support them with their recovery will be able to as long as social distancing, hand hygiene and mask wearing guidance is followed."
In Derbyshire Healthcare NHS Foundation Trust, instances of leave dropped by 263 between February and May 2020.
A spokesperson said: "For Derbyshire Healthcare, the protection and safety of patients during the COVID-19 pandemic has been a priority. At the same time, the Trust has recognised the importance of supporting those using our inpatient services with their recovery."
Due to social distancing measures, the trust saw a drop in useable acute beds and instead introduced new treatment options in the community.
“As a result of these developments, the patients that were admitted to the trust's inpatient facilities tended to be those with more acute mental ill health, which meant that it took longer for them to be in a position where it was suitable for them to have leave.“There were additional issues around the continuing need for infection prevention and control (IPC) measures and for people to isolate for 14 days at a time, which led to longer periods before leave could start across all inpatient areas. Due to the risk of infection, periods of leave were extended to prevent the risk of community infection into the ward areas. This meant that, although there were fewer leaves arranged, the average leave tended to be longer in duration.”
The trust said that, as national restrictions have reduced over summer 2021, the processes to enable usual service user leave have started to resume and added: “We are seeing a return to more normal levels of leave.”
Almost back at pre-pandemic levels
In four trusts, leave was almost back at or above pre-pandemic levels in May 2021, compared to February 2020.
A spokesperson at Leeds and York Partnership NHS Foundation Trust said: “Throughout the COVID-19 pandemic our teams have continued to adapt how our services are delivered so our service users get the care and support they need in a safe environment. As increased infection prevention measures were introduced, our inpatient wards saw reduced levels of leave.”
“We recognise that leave is often a very important part of an individual’s pathway through our services, and we have carefully considered the effects of adapting and reducing leave. This resulted in fewer occurrences of short leave and overnight leave than may have historically been used to test an individual's readiness for discharge.”
With national restrictions easing, the trust has gradually reintroduced leave.
“Our services will continue to adapt to the easing of restrictions moving forward and with that, we expect to see levels of leave increasing. Taking on board learnings from the pandemic and continually improving our services, we also expect leave may be used in slightly different ways going forwards with increased input from community services.”
The Department of Health and Social Care and NHS England were approached for a comment but did not respond.
A trust going into business continuity
When the pandemic hit, trusts were forced to react immediately.
It was the second week in March 2020 when the executive management team of Humber Teaching NHS Foundation Trust decided to go into business continuity, Adrian Elsworth remembers.
Only a week later, the first national lockdown was announced.
Adrian Elsworth is an Unplanned Care General Manager for the Mental Health Division in Humber Teaching NHS Foundation Trust.
The following months were marked by the policies and procedures that are to be followed in a business continuity position. Business continuity means having a plan to deal with difficult situations so that an organisation can continue to function with as little disruption as possible.
This especially meant following government guidelines and practices around infection prevention and control as well as putting measures in place.
Fortunately for the trust, they were in the process of permanently closing a unit — which then was transformed into a designated Covid area.
“I think we were one of the rare trusts within the UK that actually created a designated Covid area for mental health service users,” Adrian says.
Designated Covid unit and regular testing
Within a fortnight of being altered to the pandemic, 24 beds were available for patients.
“We almost refilled the unit that we had almost closed as well as moving a large staff team into that area to support those service users. That enabled us to deliver Covid-related care for mental health presentations,” Adrian says.
“Designing that area enabled us to be able to manage the spread of infection and the safety of our patients in a very different way.”
Because of the benefits, the unit has been kept to this date, although smaller in size. The last Covid mental health patient was in the unit a few weeks ago. But, Adrian says, the unit will remain in situ until such a time that nationally there is no longer a need for it.
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Jessica Slingsby, nurse matron in Humber Teaching NHS Foundation Trust, adds: “We are one of the last remaining trusts from a mental health point of view that have designated Covid areas.”
Additionally, the trust has introduced testing on all admissions, enabling them to identify cases and limiting the wider impact on the unit they were admitted to.
“We do weekly testing on all our wards now, so in that sense we’re on top of it all the time in testing and ensuring people that we are Covid safe and secure,” Jessica says.
Because of these measures, Jessica says, there have been very few occasions where they had to close their main wards due to a Covid outbreak — which directly affects the patients' leave.
“Patients have seen what happens when their leave ends up getting restricted and how that’s not conducive for their recovery. People have been there when that’s happened and then they’ve seen what we’re trying to do, that we are trying to not shut the wards. I think it’s had an overall benefit and an all-round positive outcome for both patients and staff.”
Learnings over the pandemic
“We were in a state of not knowing” — this is how Jessica describes the initial reaction to the pandemic.
Following government guidelines, she experienced a steep learning curve in the first lockdown.
“We’ve never faced this before but over the last 17 months we’ve come a long way and worked really hard to ensure that as much as possible Covid isn’t impacting on our wards.”
This included basic measures like encouraging patient isolation upon admission, wearing masks, and reducing bed capacity to ensure social distancing between patients, but also more creative procedures.
Regarding visiting, the trust created special outside areas where patients could meet with their visitors — instead of being on the wards.
Being in full PPE — in mask, goggles, gloves, aprons — all the time is not helpful for the communication with patients, Jessica says about another area where they came up with creative innovations.
“We called them PPE pocket packs,” Jessica says.
“We had masks on and tried to socially distance. But if we needed to put full PPE on because we needed to intervene because of various reasons, we had them in our pockets, so we could quickly put them on.”
This meant staff weren’t walking around in full PPE all the time “because that’s not helpful and it’s not nice for staff either”.
Their innovations around infection prevention and control did not go unnoticed. Recently, the trust was shortlisted for the Nursing Times Award.
“We’ve really tried to be innovative in how we’re working together with staff and service users to try and make this the least impact that we could possibly make.”
In the UK, the charity Mind is available on 0300 123 3393.
More information about leave from hospital can be found here:
- Information from NHS England on the Mental Health Act and Section 17 leave.
- An easy read fact sheet on leaving the ward as a detained patient.
- Information from Mind on leave for informal patients.
- Every trust should have information on the rights of informal patients, similar to this one from Rotherham Doncaster and South Humber NHS Foundation Trust.
- NHS Guidelines on visiting healthcare settings during the Covid-19 pandemic.
Get the data
Data on hospital leave in mental health inpatient services has been obtained through Freedom of Information requests. The data and analysis can be found in this GitHub repository. It also contains the data on individual NHS trusts.
Get in touch
There are many things I couldn’t cover (yet). If you have anything to add, want your story to be told or simply want to talk about the issue, send me an email or message me on Twitter.
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