In 2016, the Government set a national ambition to eliminate inappropriate out of area placements in mental health services for adults in acute inpatient care by 2020-21. In February this year, the NHS reiterated its commitment to eliminate out of area placements over the next three years, asking leaders from NHS trusts, regional teams and ICSs to develop plans to facilitate this.

Research, including a recent investigation report by the HSSIB, indicates patients who are placed out of their local areas, away from their familiar support network, are likely to have diminished trust in the mental health systems and poorer outcomes than those who are placed locally. 

A complex interplay of demand and capacity factors has made it increasingly difficult for inpatient systems to meet this ambition within their existing bed base. This includes an increase in acuity of mental health needs post-Covid, lack of appropriate community mental health provision and local drug and alcohol services, as well as delays in diagnoses of neurodevelopmental conditions. Close to 400 patients continue to be placed outside their local areas, often without their choices being considered, as of May 2024.

How systems are reducing mental health out of area placements

At a recent virtual event organised by TPHC, we heard from inpatient systems, including Central and North West London (CNWL), Avon and Wiltshire Partnership (AWP) and Sussex Partnership (SPFT), who have all achieved reductions in acute and rehabilitation placements outside their local areas. The teams shared lessons from their strategic work and brought to life both the challenges of reducing out of area placements and why it is imperative to do so.

Across the presentations, several salient themes emerged:

Understand demand and match with capacity: As Graeme Caul from CNWL said ‘it is important to understand the issue before coming up with a solution'. Caul's team has been successful in reducing out of area placements to zero for close to three years to date.

A better understanding of the trust's demand, and overall acute, step-down and community capacity can help with determining a baseline; identifying alternatives to admissions; and continuously monitoring flow and demand pressures. Analysis of how service teams were recording out of area placements helped CNWL to identify where out of area placements were happening but were contextually appropriate. For example, services in Milton Keynes had been recording out of area placements where patients were moved to psychiatric intensive care units in CNWL's wider bed base in London. This was, in fact, a commissioned pathway, and improved recording helped capture these instances, as well as other factors such as patient choice and safeguarding decision-making, which enabled CNWL to improve the accuracy of its records.

Improved data recording also enabled CNWL to actively plan for seasonal peaks to ensure better wrap around care for their population. As an early adopter in central London for the community model for adult mental health, there was a reduction in admissions, which enabled CNWL to open a new ward in Brent. To sustain the reduction in admissions, mental health crisis alternatives were implemented to alleviate pressure from emergency departments and provide immediate care for patients.

CNWL adopted a culture where ‘flow is everyone's business', which resulted in shared work on prevention, discharge planning, housing and wrap around support. This has led to an improved acute length of stay, avoided rising wait times, fewer readmissions and patients remaining close to families and support networks.

Partnership working: At Sussex Partnership, a specialist assessment team helped reduce out of area placements from 99 to three in two years. The team spoke about the importance of focusing on relationships with social care and liaising with them both pre- and post-discharge when developing social care plans. The experts on the panel from SPFT and AWP also talked about the importance of developing relationships with partners with humility (‘doing things by invitation') and coming into these partnerships with generosity of spirit and camaraderie. They stressed the importance of relationships between senior leadership across health and care organisations to help unblock issues.

Partnership working to reduce out of area placements can be complex and often involves multiple pathways. CNWL has incorporated housing support in discharge planning right from the outset and AWP has been working with the police at the health-based places of safety to reduce admissions. AWP also introduced a transfer of care hub, formed by a team of dedicated staff, to manage the inflow and outflow of admissions. This includes considering what other options are available for a patient instead of a hospital admission.

Meaningful engagement and embedding patient voice: All of the presenters acknowledged it is vital to incorporate patient voice and the lived experience of both patients and carers when designing pathways, and to ensure that patient voice and choice are respected.

 It is also important for leadership to be present and to consistently set the expectation that the move away from out of area placements is not just about saving money but is the right thing to do to bring people closer to their homes and familial networks.

Consistency is key: Hearing from presenters working in three diverse systems, there was agreement that there is no ‘silver bullet' to reducing out of area placements. The key is to continue to do the right things in a sustainable way. The presenters spoke of the value of the ‘dogged determination of a small group of people' within their trusts.  Whether it is in ensuring that the purpose of admissions and the date for discharge are consistently agreed, ensuring clinically led 24-7 bed management and flow teams are embedded, or by creating a focus on the issues through initiatives such as ‘flow fortnights' with interagency 20-minute huddles every morning.

Bringing care closer to home for good

Demand for mental health services remains high, with over 3.1m contacts across the system in just July of this year. But hearing from inspirational senior leadership, clinicians and allied health professionals made it clear that there are ways to provide a better quality of care. By focusing on the right initiatives, consistently embedding them and measuring their impact, and creating the change in culture across health and care that is necessary to ensure these are embedded effectively, inappropriate out of area placements can be reduced and eliminated for good.

If you would like to watch the recording of our virtual event, please email our communications team at TPHC to request access to it.