This is HSJ’s fortnightly briefing covering quality, performance and finances in the mental health sector.

Feedback and comments are welcome, so please feel free to email me in confidence.

Getting tough

Regulators have signalled that they are going to get tough on mental health providers sending patients out of area for treatment.

NHS Improvement announced last week it has added out of area bed days to its single oversight framework.

This could see trusts face regulatory action if they fail to reduce the time patients are spending out of area.

Each sustainability and transformation partnership mental health lead will work with commissioners and providers to agree provider level baselines and reduction trajectories with NHS England and NHS Improvement.

The change is part of the national drive to eliminate inappropriate out of area placements by 2020-21, which was set out in the Five Year Forward View for Mental Health implementation plan.

It is an important moment because it marks the point where rhetoric about out of area placements has been backed with serious sanctions that trusts will not be able to ignore. But some leaders fear the centre is just going to penalise providers, rather than offer new solutions to the problem.

Indefensible practice

No one denies that action must be taken to reduce out of area placements – with some patients being sent hundreds of miles away from home for treatment.

An out of area placement is classed as inappropriate when patients are sent out of area due to a lack of beds.

One mental health leader called it an “indefensible practice”. These placements take patients away from their families, can make care disjointed and can cost huge amounts of money.

There is no one reason for the proliferation out of area placements – some providers cite lack of beds, some point to a lack of community provision or crisis support to keep people out of inpatient units.

But leaders in one area told me their problem stemmed from high lengths of stay, meaning patients were stuck in beds when they were suitable to be discharged. This, I’m told, was due to a lack of social care – highlighting the fact that delayed transfers of care are not just a problem in the acute sector.

If we don’t know why patients are being sent out of area, how can we come up with a consistent way of reducing these placements?

Broken record

NHS Digital has been collecting out of area placement data and publishing it every month since October 2016. It will be adding the inappropriate bed days at England, regional, STP, CCG, and provider level to its dataset this month to support the entry to the single oversight framework.

After the 12 month interim period, the data will be incorporated into the mental health services dataset.

However, NHS Digital’s board agreed at the beginning of November to extend the interim collection until the end of March 2018. This was due to a lack of records being submitted to the collection, data quality issues that need addressing and providers taking longer than expected to provide the new data. This is expected to cost an extra £82,000.

I risk of sounding like a broken record but this highlights – again – the data quality issues in the mental health sector.

Without good quality out of area placement data, we cannot assess how providers are performing or help them drive forward improvements. Without good quality data, how are STPs and providers going to agree reasonable reduction trajectories?

Perverse incentives

Setting the baseline as January 2018 is also a bit like drawing a line in the sand when the tide is half in or half out. As one leader told me, it creates the perverse incentive to send patients out of area in January, so you get a higher baseline and an easier trajectory to achieve.

This is surely not what was intended.

Also, while in some cases patients are sent hundreds of miles away from home, this is not the norm. A lot of patients are sent to neighbouring NHS or private providers. For example, if you live in Cornwall close to the border with Devon, a placement in the neighbouring county might be closer to home than an “in area” placement in Penzance. As one person told me: one person’s out of area is another’s closest provision.

Many areas are coming together to set up integrated bed management functions – including the mental health vanguard MERIT. This will allow bed managers to monitor their neighbour’s beds in real time so they know where there is space available for their patients.

This means patients from Birmingham might be sent to the Black Country, or patients in Coventry sent to Dudley. On paper, they are out of area, but system leaders agree this is better than being sent from one corner of the country to another.

However, under the new out of area placement mandate, trusts could be penalised by the regulator for trying to keep these patients as close to home as possible. One chief executive said it was effectively punishing providers for working together.