Mental health repatriation ensures patients are homeward bound

In 2011, with concerns growing about the over-reliance on out of area care provision for mental health patients, a Commissioning for Quality and Innovation (CQUIN) scheme was established in Coventry and Warwickshire to tackle the issue.  

An analysis of spending on mental health services in the region at that time showed less than 50 per cent of the mental health budget was being spent on local services. A large number of patients were being treated out of the area, sometimes hundreds of miles away from friends and family. 

Historically, there had been inadequate provision locally to support complex patients with higher levels of need, so more were sent to specialist providers.

‘Assessment showed outcomes could be improved if patients were treated closer to home’

Many of these specialist care settings were costly, and had not been reviewed with sufficient frequency and robustness to ensure the care provided was still appropriate for patients’ needs.

Further assessment showed outcomes could be improved if patients were treated closer to home. And costs could be reduced and more carefully managed through local provider contracts.

This heralded the start of a successful partnership project, led by NHS Arden Commissioning Support and Coventry and Warwickshire Partnership Trust.

It aimed to deliver significant improvements in patient care, as well as more than £10m in cost savings to the three local clinical commissioning groups: Coventry and Rugby CCG, Warwickshire North CCG and South Warwickshire CCG.

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Comprehensive review

Designing and implementing a review and repatriation process required a collaborative, problem-solving approach that involved all the partners, including commissioners, local authorities and the mental health trust.

‘Although cost savings were a key driver, the patient centered focus of the project has dictated the overall approach’

The whole system was reviewed, from clinical governance, service change, training, contract management, quality assurance to performance monitoring to make the repatriation project work. An experienced team was recruited from mental health nursing and occupational therapy backgrounds with an emphasis on assessment skills.

The starting point was to identify the patients who were being cared for out of area, before conducting a clinically led, individual review of all those potentially eligible for repatriation.

It was recognised that repatriation would not be appropriate for everyone, particularly if they had already become settled in their local community and did not want to move.

Although cost savings were a key driver, the patient centered focus of the project has dictated the overall approach.

Needs assessment

Detailed work went into developing a comprehensive and transparent repatriation framework that has been refined over time. This system monitors every step of the clinical review process, ensuring patients, their families and care providers fully understand the review being undertaken.

A dedicated team of clinical specialists is responsible for each assessment, which includes:

• a review of the original needs and placement information;
• discussions with the original clinicians involved in the patient’s care and decision to send them out of area;
• assessment of the patient’s current needs and progress in the placement;
• analysis of how well the patient has integrated into their local area versus links to their home region and associated contact with friends and family;
• the availability of suitable local services that would enable that patient to be brought “home”; and
• consideration of patient and family views.

Clinical scrutiny

Recommendations are initially brought to an internal clinical scrutiny board for “confirm and challenge”. This allows clinicians, and health and social care partners to share vital information about the potential impacts of repatriating a client to the local area.

‘Recommendations are initially brought to an internal clinical scrutiny board for “confirm and challenge”’

Care options are considered, as well as the core services that would be required.

This open process is crucial in understanding historic relationships and overcoming barriers to the successful repatriation of individuals who may have proved challenging to look after in the past, and acknowledges the road to recovery may be long and complex.

The final stage is a review by the repatriation board, which is made up of representatives from all the key partners to confirm and fully risk assess the proposed move or care package changes.

In the first year of the project, June 2011 to June 2012, which focused exclusively on adults with mental health needs, 400 out of area patients were identified. By March 2014, 134 patients had been repatriated and were being cared for within the Coventry and Warwickshire area.

‘Many patients have been able to step down to a less intense service’

In 2013-14 there were fewer than 100 out of area patients identified for review, as the project has also significantly reduced the number needing to leave the area in the first place. 

So far this year (2014-15) 16 people have been repatriated and 17 have had their packages of care reduced to meet their needs. Many patients have been able to step down to a less intense service. 

In the current year there were more than 300 patients to be assessed, both in and out of area, including those with learning disabilities and dementia.

Millions saved

Every year the project has exceeded its cost savings targets, and a total of £10.5m was saved by March 2014, the end of the third year of the project.

In addition the project has avoided new costs by robustly scrutinising any plans to use out of area providers, and ensuring best use is made of local providers.

‘The relapse rate of repatriated patients is currently less than 3 per cent’

The increase in specialist beds and services locally means fewer people are now being placed out of area. However, when it is necessary, there is a clear process in place that identifies when and how that person could be brought back.

Many patients benefit from being closer to friends and family, with support to help them become part of their local community. Although in some cases families were wary about the impact of a move, working together with patients and relatives, and maintaining a transparent process throughout enabled the team to address concerns and resolve issues.

The relapse rate of repatriated patients is currently less than 3 per cent. 

Growing remit

In 2012-13, the project was expanded to a wider cohort of patients, including those with dementia. The experience and processes established for mental health repatriation have stood the region in good stead to respond to the Winterbourne review recommendations, and in 2014-15 the project was expanded again to encompass people with learning disabilities.

The dedicated mental health repatriation clinical review team has grown from five in 2011 to 11 today. It now includes specialist dementia and learning disability nurses, as well as social care, occupational therapy and secondary care specialists.

Support from local authorities has been vital in allocating resources to enable the project to benefit from a fully integrated, co-located team. Having specialist clinical experience within the team has ensured they are equipped to challenge decisions about placements and identify creative ways to provide the care required in a setting that will offer the best outcome for the patient.

Residential settings

In addition to the repatriation project, the clinical review team is now also reassessing local provision in residential and nursing homes to ensure some of the area’s most complex patients are receiving the most appropriate care in the right environment. It will also ensure local beds are available for repatriated patients.

Mental health patients can only be brought home – and cost savings delivered – if the right services are available locally. Close partnership working and information sharing has enabled local independent, NHS and voluntary sector providers to broaden the range of services they offer, enabling higher levels of need to be accommodated within the region.

With the greater level of understanding of patient needs, brought about through the clinical review process, providers are increasingly adapting and expanding services. For example, an independent provider is set to open a hospital in Coventry in 2015 to provide mental health patients with specialist acute services that have not traditionally been available within the region, outside the partnership trust’s own acute and rehabilitation services.

Postcode lottery

This project operates across three CCGs and each one has different demographic profiles and pressures. With an eye on finding efficiencies, there was the potential for the project to end up becoming a postcode lottery, with patients repatriated based on allocating an even spread of savings.

‘Work is now under way to develop a business case that could transform this programme into a substantive service from April 2015’

Thanks to the progressive attitude of the CCGs involved and a desire across the team to keep patients at the heart of the project, the approach has been regionwide, and individual areas recognise they will achieve more cost savings in one year than another.

Patients are progressed through the system based on clinical need and all partners have embraced the wider benefit of this approach, rather than being constrained by funding splits.

Business plan

Work is now under way to develop a business case that could transform this programme into a substantive service from April 2015. The team would be self-financing through the savings delivered by repatriating patients, as well as avoiding new out of area placements.

The knowledge and experience built up over the course of the project has already resulted in the identification of a new CQUIN project and has the potential to support further service redesign initiatives.

Fundamentally, there has been a change in the focus of responsibility for this cohort of patients. As an integrated team, the partners are taking responsibility for their own patients and seeking, wherever possible, to provide for them within their own boundaries.

Sally Eason is associate of service transformation at NHS Arden Commissioning Support; and Elizabeth Green is clinical review lead at Coventry and Warwickshire Partnership Trust