Brick by brick: Resources to support mental health hospital-to-home discharge planning for autistic people and people with a learning disability


Building the Right Support (2015), jointly agreed across NHS England, the Local Government Association (LGA) and the Association of Directors of Adult Social Services (ADASS), highlights the rights of autistic people and people with a learning disability to have “the same opportunities as anyone else to live satisfying and valued lives, and to be treated with dignity and respect”.

At the heart of this is their right to “have a home within their community, be able to develop and maintain relationships, and get the support they need to live healthy, safe and rewarding lives”.

The subsequent publication, Building the Right Home (2016), set out core principles; including that autistic people and people with a learning disability should have a choice about where they live and who they live with.

It states that “people can be effectively supported to live as independently as possible in ordinary housing in the community, without creating institutional models of housing and care”.

Effective planning to ensure access to high quality housing is key to enabling successful discharge of people from mental health hospitals into their own homes.

We know from the Assuring Transformation Dataset that housing is not always considered early enough in the mental health hospital discharge process.

This means that some people remain in mental health hospital settings for longer than necessary or may be given unsuitable housing and care arrangements; potentially increasing their risk of experiencing difficulties or being readmitted to hospital.

Knowledge of housing funding and legislative frameworks can vary within health and social care teams, and this can make it harder to agree a shared approach with housing partners on payments, risk sharing agreements and sustainability.

A locally joined-up approach to housing is needed.

To support this work, the NHS England Learning Disability and Autism Programme commissioned the Housing Associations’ Charitable Trust (HACT) to develop hospital-to-home discharge resources; specifically:

  1. The aims and objectives, as well as recommended strategic actions to underpin hospital-to-home discharge processes.
  2. A hospital-to-home discharge protocol template, to be used or adapted by health systems in local areas, working closely with housing and social care partners. This supports effective discharge of autistic people and people with a learning disability who are in mental health hospitals into housing that meets their needs.
  3. An individual housing needs assessment form template, to be used or adapted to align with, or strengthen, local requirements and processes.

Below we provide the aims and objectives, and wider strategic recommendations. The two templates are published separately for easy download and adaptation.

Aims and objectives

These resources support partners to create a local statement of commitment – or a local housing protocol – in which they agree to work together to help autistic people and people with a learning disability who are in mental health hospitals to be discharged into housing that meets their needs.

(See Securing strategic commitment for the protocol prior to implementation below for likely signatory organisations.)

Target audiences include health, housing and social care practitioners involved in the hospital discharge process, and those contributing to the person’s housing needs assessment.

They are likely to include social workers, clinical practitioners, occupational therapists, advocates and housing officers, all of whom are pivotal in supporting people to be discharged into a home of their own.

The network of staff supporting a person’s discharge is likely to include commissioners, specialist hospital staff, local authority housing officers, estates staff, housing benefit teams, local housing providers, and care and support providers.

Some will be involved throughout, and others may offer focused expertise at specific points on a person’s discharge pathway into the community.

Strategic leaders from all signatory organisations will be instrumental in ensuring that any locally developed protocol is adopted and aligned with a wider strategic approach to population-level housing needs assessment and delivery.

These resources focus on the housing needs of adults. However, many of the core steps and principles also support planning for the future accommodation needs of children and young people in mental health hospitals, and for young people aged 16 and 17 who need supported accommodation, although different welfare benefits regulations and legal frameworks apply to this group.

Some young people will become adults while in hospital, so effective transition planning and handover arrangements – including for future housing needs – will be essential for them.

The information below supports local areas to ensure that housing is embedded in local discharge processes.

The information below supports local areas to ensure that whenever a person is being supported to be discharged from a mental health hospital, consideration of their housing or accommodation needs is at the heart of all planning conversations and processes, from as early as possible.

This should be in partnership with the person him or herself, families and carers.

Securing strategic commitment for the protocol prior to implementation

We suggest that signatory organisations of the locally developed hospital-to-home protocol should include NHS organisations and partnerships:

  • mental health, learning disability and autism provider collaboratives
  • NHS mental health trusts
  • independent sector mental health hospital providers
  • integrated care boards (ICBs)
  • local authorities (both those responsible for housing and for social care, which in ‘two tier’ local government areas will be different organisations – see Local government structure and elections)
  • housing providers
  • care and support providers
  • other local independent and voluntary organisations.

Implementing the hospital discharge protocol

Local partnership arrangements and configurations will differ, but to be successful a local protocol must be adopted by all key organisations involved in supporting people’s discharge from hospital, and embedded in all relevant frameworks and processes.

It should align with Dynamic Support Register (DSR) processes, the Care (Education) and Treatment Review (C(E)TR) approach and legal responsibilities held by local agencies – for example, in relation to mental health legislation, the Care Act 2014 and the Mental Capacity Act 2005.

The protocol should reference the overarching strategic commissioning plans for the local area and be actively supported by senior leaders and managers from all the named organisations.

This may require endorsement in multiple governance frameworks (for example, those applying to local health, housing and social care systems and at different levels of geography), particularly if implementation of the protocol requires any changes to working practices and caseloads.

We suggest that the protocol should be a signed document and have a start date and timeframe for review, to ensure that it is kept ‘alive’ and up to date.

12-point discharge plan and DSR and C(E)TR policy

The local approach to hospital discharge should be implemented alongside the 12-point discharge plan (when planning the discharge of autistic people and people with a learning disability).

This was introduced as part of the Assuring Transformation Dataset reporting requirements, and can be found at Appendix 7 of the DSR and CETR policy and guidance.

Point 7 is ‘Accommodation search’ and point 3 ‘community accommodation and support capacity assessment’, which is completed much earlier, should include individual housing needs assessment and helping people to plan ahead.

We recommend that professionals responsible for C(E)TRs and DSRs consider the principles outlined in this resource and ensure that individuals’ housing needs are discussed during C(E)TR and DSR meetings.

Alongside the operational steps, we recommend some wider strategic actions to ensure the availability of an ongoing pipeline of suitable housing options for people to move into from mental health hospitals.

These strategic actions are:

  1. Strategic housing needs assessment (led by the local housing authority, in partnership with commissioners), including analysis of:
  • qualitative intelligence drawn from engagement with people and families
  • population level health and social care needs analysis
  • any recorded housing needs data about individuals living in mental health hospitals (eg as captured in individual housing needs assessments, C(E)TRs and other local intelligence)
  • housing needs of people placed in hospital or other institutions far from home
  • housing needs of young people coming up to adulthood
  • details of the housing pathway and all current options for accommodation, from short-term step-down accommodation services and general needs housing (with adaptations if required), to specialist long-term housing arrangements.

This data should be used to inform local housing delivery plans as follows:

  1. Strategic housing delivery plan(s) led by the local housing authority, in partnership with commissioners and housing providers, capturing:
  • types of accommodation required, and where they are needed
  • needs that can be met through general social housing provision, and those requiring investment in refurbished properties or new build schemes; include any need for short-term/crisis accommodation
  • targeted action on specific issues, such as risk sharing on housing ‘voids’ to cover costs when housing is necessarily empty; or to amend the social housing application process to ensure access for autistic people and people with a learning disability
  • how community health and social care teams (whether learning disability, autism or mental health) will support housing and care staff, to help prevent future mental health hospital admissions
  • information from engagement with local housing delivery partners about their capacity to generate the additional supply needed
  • capital funding requirements to underpin the housing delivery plan – an agreed local approach to sourcing the range and level of capital funding needed
  • any need for reasonable adjustments to local homelessness services for autistic people and people with a learning disability.