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Posted on Mar 24 2021 by Bobbie Kelly

Recovery doesn't end the moment you're discharged from hospital; to thrive in the community, people need ongoing support. 

Here, Dr Sally Foster, Consultant Forensic Psychiatrist, shares her thoughts around the ongoing support people should have in place.

"The mental health patients I work with come from many different backgrounds and situations; some have forensic histories, which means that they were in contact with the Criminal Justice System before being assessed for mental health treatment, and others come to us because there's no suitable care for them within the National Health Service.

Once patients are discharged from St Andrew's, the next stage of their recovery journey is out of our hands, but sadly we too often see patients discharged who then come back to us further down the line. Thankfully, at St Andrew’s we’re part of the Assertive Transitions Service, a pilot approach which means that each patient has additional support for up to a year before they leave hospital. The Service works with patients on the ward to identify barriers to a successful discharge, and formulate a comprehensive package of care for them. Once the patient leaves us, they receive three months' intensive support as they reintegrate into the community.

The Assertive Transitions Service recently supported one of my patients who had made great progress in his recovery. It was very clear that he was going to be discharged very quickly, and as he was in our care following his first episode of illness, he wasn't in touch with any community team. The first challenge was accommodation - he was going to be discharged with nowhere to go, and he was unable to return to his home area due to restrictions placed on him by the Ministry of Justice. He had no bank account, no idea where he wanted to go, a history of substance misuse, and a criminal record.

What he did need was a chance, a chance to thrive in his new life after working so hard on his recovery. We worked with him on his ward before he was discharged, got to know him and his history, his likes and dislikes, his worries and fears. We wanted to ensure we could navigate some of the challenges he was going to face, so we worked with local teams and accommodation providers to sort him a place to live. When he left our care he had access to support from substance misuse and alcohol support services, and advice on how to budget and manage his self-care.

I believe if he hadn't have had this support in place upon discharge, he'd probably have ended up in prison.

His is, unfortunately, not a unique story. Right now at St Andrew’s we have around 50 patients who are in our care, yet fit for discharge. They no longer need inpatient mental health care and treatment; what they do need is to start their lives afresh in the community. My hope is that the Assertive Transitions Service - working closely with other partner organisations, will be able to help people move on in their lives faster, with everything they need in place to thrive."

What is the Assertive Transitions Service?

The Assertive Transitions Service (IMPACT) was launched in February 2020, providing personalised, proactive support to low and medium secure care inpatients up to a year before discharge and then for three months in the community.

This pilot (to March 2021) sees enhanced ward in-reach and integrated community support delivered by two multi-disciplinary teams in the north and the south of the East Midlands region. 

The ATS was developed based on insight from service-users and staff which identified a real need for practical, pre-discharge support to ensure smooth, successful and sustainable transitions to community living.

Find out more on the NHS Nottinghamshire Healthcare website, here.

Dante's story: How the Assertive Transitions Service is preparing him for discharge

Dante is a St Andrew's patient who is being supported, ready for when he is discharged. Watch his story below by clicking the photo below and hear, in his own words, why he feels prepared for life outside of hospital.