Improving the Adult Patient Journey

Across London, health and social care services are under increasing pressure, and South West London is no exception. We continue to experience sustained high demand across our health system, with particular strain on mental health services - especially within working age adult services in the community and across the acute and urgent care pathways.

A growing number of individuals with complex mental and physical health needs are accessing emergency services during crises, often resulting in them being in inappropriate settings - such as prolonged waits in Emergency Departments or out-of-area placements, far from their support networks.

Ensuring effective patient flow is critical to delivering timely, appropriate care. However, we are seeing a rise in long stays on adult acute wards, particularly among those with stays exceeding 90 days. Delays in discharge and challenges in securing suitable housing or supported placements continue to be significant barriers across the capital.

In response, over 2024/25, we increased the use of local external beds through a private provider to meet the demand for inpatient treatment. However, our data shows this did not result in an increase in overall admissions, suggesting we had not addressed the underlying issues contributing to our overall growth in length of stay.

We recognise that extended stays in restrictive inpatient settings – especially after a patient is clinically ready for discharge – can hinder recovery. These delays disproportionately affect individuals from Black, Asian, and Minority Ethnic backgrounds.

We are committed to addressing these challenges through partnership working, co-production, and a focus on active anti-racism and continuous improvement.

How does the Adult Patient Journey tackle these challenges?

The Adult Patient Journey (APJ) programme addresses system-wide challenges by bringing together our community, acute and specialist services to improve the entire care pathway. The focus is on ensuring timely access to high-quality care - both in the community and in inpatient settings - and supporting individuals to return home, or to appropriate settings as soon as they are ready, ideally remaining close to their local communities.

The programme aims to foster a culture of continuous improvement as we seek to provide purposeful, timely, and least restrictive care that supports recovery. We have strengthened our collaboration with partners, including social care colleagues, to better respond to these pressures.

The programme is data-led and over the year we have worked to understand and better use health inequalities data (including ethnicity data) to understand the impact of our work and guide our interventions.  

A core principle of the APJ programme is co-production. We work closely with service users, carers, and families, ensuring that people with lived experience of mental health services are actively involved in shaping improvements to care.

Adult Patient Journey Programme: Principles, Enablers and Progress

Guiding Principles: The Adult Patient Journey (APJ) programme is built on four core principles to ensure high-quality care that is:

• Purposeful: Every intervention should have a clear therapeutic goal
• Avoids crisis: Proactive care to prevent escalation
• Timely and Least Restrictive: Support delivered promptly and in the least restrictive setting
• Recovery-Focused: Enabling individuals to regain independence and well-being.

Key Enablers

Fundamental Standards of Care: A consistent framework to define and measure the quality of care for every patient.
Digital Innovation: Leveraging technology to enhance care delivery and coordination.
Programme Focus Areas

The APJ programme is structured around three priority areas:

• Improving Community Services
• Enhancing the Crisis Pathway
• Reducing Average Length of Stay

Introducing DIALOG+ care planning in the community

We are changing how we work with patients and carers in the community to plan care, with the introduction of DIALOG+ care planning. This is the first step in moving away from the Care Programme Approach (CPA). Towards the end of the year, we began to pilot the implementation of DIALOG+ to work with all CPA patients, carers and families to plan care in a holistic and personalised way. This means that patients and carers work with staff to answer 11 simple questions to rate their satisfaction and needs for care across different parts of their lives and treatment. The DIALOG scale helps to guide a structured conversation between a health professional, the patient and family that is patient-centred with a focus on key areas the patient would like to improve. 

Reducing very long length of stay

Our adult acute inpatient average length of stay remains above the national average, which tells us that some adults, who could be better supported in out-of-hospital care in the community, are spending extended periods in restrictive inpatient care. Over the past decade, our overall length of stay has increased by nearly 40%, largely driven by rising numbers of patients staying over 90 days. This trend is affecting both our ability to respond to crises and our financial sustainability.

Toward the end of the year, we made significant progress in safely discharging patients with very long stays. We must now maintain this momentum to achieve a 26% reduction in average length of stay by March 2026, which will also help us reduce reliance on private sector beds.

Progress so far:

• Work to safely discharge some of those patients with the longest lengths of stay (above 90 days). We have supported more people to be discharged from hospital while maintaining a very low rate of readmissions.
• Collaborative efforts to reduce external and internal discharge delays have led to fewer bed days for patients who are clinically ready for discharge.
• Continued our plans to reduce external beds and avoid out-of-area acute bed usage. 

However, challenges remain, and next year we will continue to focus on:

• Addressing our long length of stay and delivering improvements to the quality of care
• Patients who are clinically ready for discharge, particularly where delays are linked to Ministry of Justice, housing, supported placements and packages of care. 
• Number of our community patients presenting to emergency departments. We need to work with the system to ensure timely admission for those who need it most, including patients having over 12-hour waits.

Quality Improvement projects in action

Three innovative Quality Improvement and Innovation (QII) collaboratives have tested a range of ideas across the year aimed at optimising hospital stays to reduce length of stay, keeping people well, and reducing crisis in the community. They are in their final PDSA (Plan-Do-Study-Act) cycle with successful ideas to be widened and learnings from our first wide-scale use of QII to inform 2025/26 plans. 

Improving mental healthcare in Emergency Departments: The Trust receives 15-25 referrals a day from emergency departments for people with urgent mental health needs. When people arrive in emergency departments, collaboration between hospital teams and our psychiatric liaison mental health service is key to ensuring they receive rapid and appropriate care. To address the challenges, Kingston Hospital is part of a rapid assessment pilot supporting patients arriving in emergency departments to get to the most appropriate service as speedily as possible. A hospital support worker quickly screens patients showing signs of mental distress to see if they need immediate assessment. This means our psychiatric liaison teams can prioritise the most acutely unwell patients who need complex clinical care. 

In February, St George's Hospital’s team began trialling a similar triage system to ensure patients get the right care as quickly as possible. The Mental Health Navigator project aims to improve the crisis pathway to provide immediate support to people arriving with mental health needs. At the heart of the pilot is a ‘Mental Health Navigator’, based right at the front door of the Emergency Departments, offering a calm presence, a listening ear, and quicker access to the right care.

The navigators are experienced in crisis support and work closely with the streaming nurse, who screens patients early on to direct them to the most appropriate service. Together, they support people with lower-level mental health needs by identifying each person's needs as early as possible and directing them to the right service. This could include a rapid assessment clinic, their GP, community mental health teams, or voluntary organisations offering help with issues like housing or benefits.

Preventing relapse with Lavender Ward and Sound Minds: Lavender Ward, for acute adult inpatients, sees some of our most unwell service users – and for some, it is not their first stay, having unfortunately relapsed after leaving hospital. A former service user noticed that one of the reasons people relapse is a lack of support in the community after relationships weaken while they are in a hospital. In order to build supportive relationships, a new project sees inpatients supported to visit a service-user-led mental health arts charity, Sound Minds, which delivers peer support to people with mental health conditions through music, film and art. The hope for this project, co-produced with clinicians and people with Lived Experience, is that this extra focus on our patients’ recovery can help to prevent relapse, helping patients to get better and also freeing up beds for those who urgently need to be cared for on a ward. 

Removing barriers to discharge with Burntwood Villas: Burntwood Villas rehabilitation ward cares for people who may have spent a long time in inpatient services, empowering people to live as independently as possible before they rejoin the community. However, sometimes people spend longer than expected at Burntwood Villas, even when they are clinically ready for discharge; this is restrictive for patients and is not recovery-focused. Team manager David Denteh has worked to improve the way his multidisciplinary team collaborates to assess each patient’s readiness for discharge, ensuring everyone brings and discusses the right information about each patient. The aim of this is to make sure everyone considers the correct moment to discharge service users to the next stage of their care. The team now makes better use of digital tools, has removed duplication, and colleagues can now deputise for David, saving him time each week, which he can spend with patients instead. In the first few months, the team helped three of their patients return to the community and continue their recovery journey.

Performance against objectives

The table describes how we have performed against our objectives, in terms of outcomes and metrics. We reviewed our delivery of this at the May 2025 Board.