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Posted on Sep 4 2020 by Jo Lehmann

To end out-of-area mental health placements, providers must recognise their part in the problem and be prepared to change

By Jess Lievesley, Deputy Chief Executive Officer

Across England there are more than 1,700 patients in mental health facilities miles away from their home areas. Freedom of Information requests made by the Royal College of Psychiatry earlier this year revealed that 11 of 23 Clinical Commissioning Groups had placed patients out of area. In our care, roughly 1/3 of our patients are with us because they’re unable to get the help they need close to home.

Having been responsible for commissioning non NHS-placements in previous roles, I too have been guilty of placing individuals out of area myself, so I recognise first-hand the challenges faced by commissioners who are often searching for services to keep people safe despite a lack of a suitable available beds. I’m not seeking to blame anyone for the problem, far from it; commissioners and providers alike have been faced with an impossible task of balancing the needs of those in their care against finite local resources.

But there is consensus for change. The ethos which has driven mental healthcare over the last two decades is absolutely the right one – that is moving care closer to home, providing more individualised packages of care and doing so, wherever possible in the community. This of course forms the basis of the NHS Long Term plan and the Five Year Forward view for mental health, and you’d be hard pressed to find anyone who disagrees with these policies.

But - and there is always a but - these policy ambitions require a joined up way of funding and supporting individuals as they recover. Too frequently the divisions between commissioning authorities, be it the NHS, Local Authority or a combination of the two, are not set up in ways that allow the seamless transition of the individual between the right levels of care and support.

As a provider of mental healthcare, we must be willing and ready to change, so we become part of the solution rather than perpetuating the problem. For too long organisations like ours were accepting patients from all corners of the country because there was no provision for them in their local areas. This quickly became a cyclical problem, because there was no need for authorities to develop bespoke solutions for people with complex needs within their local population.

This pattern of out of area use, coupled with strained local resources created a problem for providers like us who grew too big in a bid to meet the national need, resulting in inconsistencies in the level of care. The most obvious case in point was our 110 bed Child and Adolescent Mental Health Service, the largest facility of its type in Europe.

Our role should be to provide the services the system needs us to provide, not grow for growth’s sake. We are therefore currently ‘rightsizing’ our charity and reducing our services in areas where the system as a whole needs to find better solutions than inpatient hospital care.  Our CAMHS service is in the process of reducing to 30 beds, and we will continue to work with housing and other partners to find solutions that support people to move on from secure care.

By significantly reducing the number of people cared for in inpatient settings and focusing more on community care, providers can actively force the system to change. But it requires a concerted and collaborative effort so together we can achieve the same common goal. That’s not to say that we’re heading towards an era where mental health hospital care will no longer be required, as there will of course always be a requirement for it- but it needs to be focused, targeted and fit for purpose.

A lack of local solutions and adequate community provision can also result in the delayed discharge of patients. We have between 50-60 patients in our care who are ready for discharge and no longer have any clinical need to be with us. I would estimate that across the country 10 percent of patients in Mental Health and Learning Disability facilities are medically fit for discharge, but are stuck because there is no adequate community provision for them. In circumstances such as these people would be right to say the system is letting them down.

This is where the new Provider Collaboratives model is playing a valuable role. From April of this year, NHS England and NHS Improvement have been rolling out plans which see local service providers from a range of backgrounds, including the voluntary sector, NHS trusts and independent sector, working together with the common goal of reducing the number of people who are cared for out of area, as well as ending the practice of delayed discharge. The Provider Collaboratives allow specialised providers to invest in other parts of the local health system particularly community care, which is so desperately required.

It is clear that change is afoot across the mental health and learning disability sector.  I have worked in the sector since I was 17, and I have never been more optimistic that things can change. That said if we stand still then we all become part of the problem. Those who use our services as well as their families are depending on us all to commit to make these changes.