We explore why mental health patients often find that the only services available are far from their homes

Out of area treatment is common in mental health. Patients who need a secure environment, have rare conditions or even who have a double diagnosis of mental health problems and drug or alcohol misuse can be placed far from home in specialist units.

It has long been recognised it can have both positives and negatives for the patient: while they may be getting the specialist treatment and care they need, reintegrating them into their community is likely to be harder. They may lose contact with friends and family and may be harder to slot into a rehabilitation pathway locally.

It is not surprising many commissioners have seized on out of area treatments in their search for savings

But unnecessary out of area treatments may also be bad for the public purse. They can be more expensive than local treatment and the problems with monitoring them means they may last longer than clinically indicated − patients who are reviewed yearly, for example, are unlikely to be returned to their local area between reviews.

Counting costs

In 2010 the Royal College of Psychiatrists published research saying £300m a year was being spent on out of area treatments, which were on average 66 per cent more expensive than local treatments. More than one in five of all patients undergoing rehabilitation were being treated outside their local area.

So it is not surprising that many commissioners have seized on out of area treatments in their search for quality, innovation, productivity and prevention savings. A briefing from the NHS Confederation’s Mental Health Network and other bodies last year suggested commissioners needed to understand how many placements they were making out of area and why, and then develop strategies to reduce inappropriate placements.

The barriers to more local treatment can be substantial but are by no means insurmountable. “It’s partly capacity, it’s partly skills and partly attitude,” says Chris Naylor, senior fellow at the King’s Fund. Capacity issues can include supported accommodation or step down care for people coming out of a more institutional environment.

Training and skills

Skills shortages can be around caring for patients within community settings and what skills the local team have. For example, patients with complex needs, such as substance abuse combined with mental health issues, can be seen as too challenging for local services.

“They will set eligibility criteria and say they can’t deal with these people and they need to go elsewhere,” he says. “Some of the areas that have managed to reduce out of area treatments have looked at skills in their teams and training them up.

“But there is also an attitude issue − a perception about who is responsible for meeting their complex needs. If the prevailing perception is you don’t do this, you send them elsewhere that can contribute. Some people have had to work with GPs to change referral patterns so they don’t assume that someone needs care a long way away.”

Reducing unnecessary placements is a typical invest to save policy: PCTs and CCGs will need to work with local providers to build capacity to enable the transition to begin. But where this has been tried PCTs have had some success, often working with local authorities.

Big savings from careful review

The PCT cluster in Derbyshire was quick to identify out of area treatments as a QIPP target - and made savings of close to £3m last year as a result.

The cluster built on work done in 2010-11 in Derby City to set up a system which ensured that patients placed out of area were carefully managed and reviewed.

This has four main approaches:

  • all placements were to be reviewed regularly, outside the four to six monthly care programme reviews;
  • every patient to have an expected date of discharge from the out of area provider, together with a discharge plan, which looked at the sort of environment they would be likely to move into;
  • ensuring patients were in the most appropriate setting for their needs, eg security level;
  • ensuring that, whenever possible and appropriate, patients were placed close to home. In some cases, patients who have undergone rehabilitation choose to remain in a new area and for some substance abusers returning to their old environment would not be helpful.

An individual placement panel was set up to look at all cases, with case coordinators reporting back to the panel three months after a placement is made. Georgina Horobin, mental health commissioning manager, says that some additional funding was used to employ five case managers.

In 2010-12 the new system had a target of making savings of £3.7m. It achieved 79 per cent of this − £2.93m − but was able to return many people to care closer to home. The number of people in out of area placements has now stabilised. This year it has a cost savings target of £770,000.

Ms Horobin says: “There were quick wins in the first year − people who had been placed out a long time and just needed a pathway home.”

She says an excellent database has helped - ensuring individual patients are tracked − as has some development of local services, such as additional funding for an eating disorder service and new provision by an independent provider in the county.

Derbyshire Healthcare Foundation Trust − the local mental health provider − has worked closely with the trust and has opened a new 10-bedded female unit which has helped transfer some patients back.

Building capacity

And commissioners are likely to find that their local mental health trusts are keen to work with them to bring patients home. In south east London Oxleas Foundation Trust has worked with both PCTs and social care commissioners to reduce the number of patients treated out of area.

We had to get services to think more flexibly about what they could provide and how they can adapt

Complex needs and recovery services director Iain Dimond says that patients were placed out of area because of a perception that their needs were particularly complex and could not be met within the local services. The approach has involved reassessing what could be done locally and also vigorously reviewing out of area placements to ensure they were offering value for money.

“It is about getting the whole system to sit down and acknowledge that it is a problem,” he says. “It costs a lot of money and we are not necessarily getting good outcomes from out of area treatments.”

For commissioners − who might be looking for year-on-year reductions in spend − it offered the chance to save money and potentially improve outcomes. Reviewing cases started from asking a simple question: “What kind of package of care would it take to get these people to live as independently as possible in their communities?” he says. “We have had to get our existing services to think more flexibly about what they could provide and how they can adapt the service to manage a person’s behaviour.”

Positive attitude

Often these solutions needed to be tailored to the individual’s needs. One patient with enduring mental health problems who was also hearing impaired had been placed in the North West in a very expensive facility.

To return the patient to their home area meant that staff at one facility had to be trained in sign language. But they are now able to cope with the patient’s behavioural issues and link them into the local deaf community.

In Bromley, 12 people were placed out of area four years ago and this has been reduced to three, with no new placements for the past three years. In Greenwich, the number has fallen from 21 to three and in Bexley, where work has started more recently, numbers have already fallen from 13 to six.

A handful of providers want to hang on to patients. But with some of these placements costing up to £2,000 a week, offering “a bit of challenge” is important, he says. “It is about taking providers to task about what it is you are getting for this investment,” he says.

Minimise risk

Oxleas has been fortunate in employing a part-time member of staff solely on the issue of repatriation, who is involved in the review meetings.

Mr Dimond also stressed the importance of a positive attitude towards risk, seeking to minimise the risk some of these patients present to themselves or others. This can involve, for example, changing staff rotas to reflect this.

Mental Health Network acting deputy director of the Rebecca Cotton feels out of area treatments remain an issue that can be looked at with potential benefits for patients.

But she cautions: “For some specialist conditions it is only ever going to be clinically appropriate to do things on a regional or even national level. We will always need some of these placements.”