When a patient is ready to step down from inpatient care, the clinical picture and the commissioning decision do not always move at the same pace. Clinically, the team may be confident but for the commissioner or referrer signing off on a community placement, particularly for someone with a complex mental health history, you need to have confidence in the service provider too.

There is a longstanding assumption in our sector that hospital is the safe option and community is the risk. I understand where it comes from but it’s not the truth for everyone, and in so many cases it can actively work against the person at the centre of the decision. Prolonged inpatient stays beyond what is actually clinically necessary carry real costs for the patient. These include the loss of independent living skills and a weakening of community ties. In addition to this, losing their ordinary daily routines of life that recovery ultimately depends on. 

How safety gets built in a community setting

In an inpatient setting, safety tends to be visible:

• Observation levels
• Staffing ratios
• Immediate clinical oversight. 

In community-based support, the same goal is achieved through different means.

At Bridge Support, our safety starts with knowing the person well, really well, and that shapes every aspect of how we staff and structure our services. When a small, consistent team works alongside someone over weeks and months, they develop a knowledge of their patient in a way that no risk assessment form fully captures. They know what a settled period for them looks like. They are able to recognise the signs that something is changing in the person long before it gets to crisis stage and they can have the difficult conversations because they’ve built trust and rapport.

Knowledge like this takes time to build and it depends on staff continuity. We treat high turnover as a quality issue because at the base of it that’s what it is. When the faces change too often, the relationship based foundation that supports good risk management starts to break down. We monitor consistency closely and we structure our services to protect it.

But, of course, the practical day to day structure is very important too. Every person we support has a personalised risk management plan. These plans are created with input from our client and alongside the clinical and social care professionals in their network. The plan is regularly reviewed and easily changed if neccessary. Staff know how to escalate an issue, they know the thresholds, they know who to contact and they know how to act before a situation deteriorates. We maintain excellent working relationships with local crisis teams and CMHT colleagues because those are the relationships that must be in place before they are needed in an emergency.

What if something goes wrong?

Commissioners ask this question, and they absolutely should. If a provider can’t answer the question, that’s a red flag right there.

From our point of view, when an issue comes to light at Bridge Support, the pathway is defined and followed and the relevant clinical contacts are informed as soon as possible. If there’s an urgent concern about someone’s safety, the response is fast and the escalation is direct. We communicate and we keep all the necessary people informed.

That includes commissioners. If a significant incident happens with someone in our care, the relevant people hear about it from us, quickly and honestly. Transparency is not something we reserve just for good news.

On the question of track record

I am not asking commissioners to take our word for any of this. Track record is what matters, and ours is built on years of working with people whose needs are at the complex end of the spectrum. People with forensic histories, people who have spent long periods in inpatient care, people for whom previous community placements have not worked.

Some of those referrals come with a degree of hesitation from the referring team. That is understandable. What we have found, consistently, is that the hesitation tends to give way once people see how we work in practice. The visits, the conversations, the reviews. The willingness to be looked at closely.

Community support is not the right option for every stage of the recovery pathway. But for people who are clinically ready to step down, a person who is ready to leave hospital shouldn’t still be there because the right community support couldn’t be found for them.

If you are looking at a referral and want to understand how we would approach it, I am happy to talk it through.

Further Reading

Making a Difference: Community Link Workers

The Importance of Community in Mental Health Recovery

Partnership Working That Actually Works: How We Collaborate With Clinical Teams