HEALTH SERVICES SAFETY INVESTIGATIONS BODY – OAP’s OUT OF AREA PLACEMENTS
https://www.hssib.org.uk/patient-safety-investigations/mental-health-inpatient-settings/
We investigate patient safety concerns across England to improve NHS care at a national level.
Investigation report
Mental health inpatient settings: out of area placements
Date Published: 21/11/2024
About this report – Brief Summary see full report at: https://www.hssib.org.uk/patient-safety-investigations/mental-health-inpatient-settings/
In June 2023 the Secretary of State for Health and Social Care announced that HSSIB would undertake a series of investigations focused on mental health inpatient settings. This report is the third report in the series. In October 2024 HSSIB published a report titled ‘Creating conditions for the delivery of safe and
therapeutic care to adults’ and in September 2024 HSSIB also published an interim report titled ‘Creating conditions for learning from deaths and near misses in inpatient and community mental health services: Assessment of suicide risk and safety planning’.
This is one of a series of HSSIB investigations on the theme of patient safety in mental health inpatient settings. This investigation explored the issue of out of area placements (OAPs) – that is, scenarios where a patient is placed in a mental health inpatient setting that is a long way from their home or usual place of residence.
Theme: Mental health
This investigation explored the issue of out of area placements (OAPs) – that is, scenarios where a patient is placed in a mental health inpatient setting that is a long way from their home or usual place of residence. Below is a brief summary- link above to full report.
OAPs can cause harm to people, from the increased anxiety caused by a new and unfamiliar setting, to developing complex post-traumatic stress disorder because of the way in which they are transported and detained in an OAP.
The Mental Health Act Code of Practice requires that patient, family and carers’ choice is taken into consideration when making decisions about where a patient should be placed. It also requires that every effort is made to place a person as close to home as possible. Patients, families and carers of adults and children may not be asked about their choices and views on OAP.
The investigation found that harm (including dying by suicide, physical, psychological, Distress and anxiety) was happening to patients, families and carers because of OAPs and the impact of being far away from their normal support network. There was also significant anger, frustration and loss of trust in the mental health system as a result of their experiences
The investigation found that OAPs can increase patients’ length of stay in hospital and therefore contribute to harm to patients.
Patient, family and carers’ wishes and preferences, as required in the Mental Health Act 1983: Code of Practice, are not documented by health and care staff or routinely monitored during Care Quality Commission inspections. This leaves patient, families and carers feeling they are not listened to and increases anxiety, frustration and anger, leading to harm for people and creating distrust in the system.
Advocacy services are vital for a patient to be able to put forward their views for consideration in decision making about their care, but advocacy is not always offered to patients.
The rules, governance and legal framework within which health and social care organisations’ work differ. This can create friction in the system, preventing integration and pooling of funds across organisations, slowing down discharge and patient flow, and is a significant factor in the use of OAPs.
It is impossible to look at the mental health inpatient system in isolation; consideration must be given to other health and care services such as HSSIB makes the following safety recommendations Safety recommendation R/2024/042:
HSSIB recommends that the Department of Health and Social Care includes the documenting of patient, family and carers’ wishes and preferences within the Mental Health Bill. This will ensure all patient, family and carer voices are community mental health services, social care and social housing provision by local authorities.
When patients are sent to OAPs, the sending hospitals do not maintain responsibility for the welfare or clinical oversight of those patients.
Limited patient flow through mental health and other services reduces trusts’ ability to discharge patients from hospital, which can increase the use of OAPs.
NHS mental health trusts do not always have local authority social workers embedded in their organisations, as used to be the case under previous working arrangements.
Embedding social workers within trusts was viewed by social workers and healthcare staff as a benefit to patients and improved patient flow and discharge planning.
Some NHS trusts are undertaking some of the functions of local authorities relating to social housing, in order to enable patients to be discharged and reduce the need for OAPs.
Beds and patients are managed in an impersonal way without seeing patients as having individual requirements. They are both treated as “commodities” when deciding on the need for an OAP because of the pressure on services and need for acute mental health beds.
Crisis resolution and home treatment teams can have a significant influence in the early discharge of patients, that then creates a bed for the most mentally unwell patients in the community.
Hospitals that send patients out of area sometimes rely on Care Quality Commission rating to base OAP decisions on, but many of these ratings are out of date and may not reflect the current situation.
Many acute mental health patients have neurodevelopmental conditions and would benefit from early testing when they are in contact with community and acute mental health settings. Early assessment makes sure people are placed on the right pathway and may reduce admissions to acute mental health settings and the need for OAP.
Safety recommendation R/2024/042:
HSSIB recommends that the Department of Health and Social Care includes the documenting of patient, family and carers’ wishes and preferences within the Mental Health Bill. This will ensure all patient, family and carer voices are community mental health services, social care and social housing provision by local authorities.
When patients are sent to OAPs, the sending hospitals do not maintain responsibility for the welfare or clinical oversight of those patients.
Limited patient flow through mental health and other services reduces trusts’ ability to discharge patients from hospital, which can increase the use of OAPs.
NHS mental health trusts do not always have local authority social workers embedded in their organisations, as used to be the case under previous working arrangements.
Embedding social workers within trusts was viewed by social workers and healthcare staff as a benefit to patients and improved patient flow and discharge planning.
Some NHS trusts are undertaking some of the functions of local authorities relating to social housing, in order to enable patients to be discharged and reduce the need for OAPs.
Beds and patients are managed in an impersonal way without seeing patients as having individual requirements. They are both treated as “commodities” when deciding on the need for an OAP because of the pressure on services and need for acute mental health beds.
Crisis resolution and home treatment teams can have a significant influence in the early discharge of patients, that then creates a bed for the most mentally unwell patients in the community.
Hospitals that send patients out of area sometimes rely on Care Quality Commission rating to base OAP decisions on, but many of these ratings are out of date and may not reflect the current situation.
Many acute mental health patients have neurodevelopmental conditions and would benefit from early testing when they are in contact with community and acute mental health settings.
Early assessment makes sure people are placed on the right pathway and may reduce admissions to acute mental health settings and the need for OAP considered in decisions relating to where the patient identifies they would like to be close to, for example the patient’s home or a family member, specifically when an out of area placement is needed.
Safety observation O/2024/043:
Mental health inpatient services can improve patient safety by offering advocacy to all mental health inpatients at the point of admission, and ensuring that the patient’s decision about whether or not to have an advocate is continually reviewed as their treatment continues and needs may change. This can ensure that patients’ needs and views are taken into account by health and social care staff when decisions about their care are being made, particularly when in an out of area placement.
Safety observation O/2024/047:
Healthcare services can improve patient safety by conducting assessments for neurodevelopmental conditions such as autism and attention deficit hyperactivity disorder, where it is safe and clinically indicated, at the earliest opportunity when a person is in contact with community and acute mental health services. This can ensure that patients are put on the appropriate pathway early. This can prevent harm that may be caused by receiving inappropriate treatment and reduce admissions to mental health inpatient settings, thus reducing the need to use out of area placements.
1.2.5 Acute adult inpatient wards are provided by NHS trusts and independent sector hospitals (for private and/or NHS-funded patients). Wards in the NHS are ‘commissioned’ (planned, purchased and monitored) by integrated care boards (ICBs) (NHS England, 2024b). ICBs are part of integrated care systems as defined in the Health and Care Act 2022 and plan health services for their local populations
1.2.6 In acute settings all staff have a duty to ensure that patients are subject to minimum or least restrictive practice that is appropriate and the restrictions should be for the least time possible (Department of Health, 2014). Restrictive practices are techniques used to manage a patient’s behaviour to prevent them from harming themselves or others. They include practices such as physical restraint, seclusion, rapid tranquilisation and continuously being close to and watching a person (observation).
1.3.5 Patients can be discharged from an OAP to their normal place of residence, a carer or family member or to social housing if needed. The same can be said for patients in NHS acute care. Not all patients who are in an OAP or NHS acute service need social care or housing support on discharge.
Section 75–this section enables NHS bodies and local authorities to enter into arrangements which are prescribed in secondary legislation. The NHS Bodies and Local Authorities Partnership Arrangements Regulations 2000 (UK Statutory Instruments, 2000), as amended, is the relevant secondary legislation that sets out details of the permitted arrangements. This can include pooling of funding and resources across health and social care services that can benefit patients.
1.4.4 Section 130 of the Act relates to independent mental health advocates
(IMHAs). Patients who qualify under the terms of the Act are entitled to an IMHA who will be assigned by the local authority. Advocacy is a ‘means of getting support from another person to help you express your views and wishes, and help you stand up for your rights’ (Mind, 2018).
2.1.3 The patient, who was diagnosed with autism and a mental health problem, was on an acute ward and had begun to feel “anxious and disturbed”. They began showing signs of increased personal risk-taking behaviours, and staff believed that the patient needed to be transferred from the acute ward to their psychiatric intensive care unit (PICU). The PICU was full so the decision was made to transfer the patient to an independent OAP provider’s PICU which was 150 miles away. The patient went to bed as normal, believing that they would be going to the hospital’s PICU sometime during the next day. The patient was woken in the early hours of the morning by several members of staff and told to pack their personal belongings because they were being transferred to an OAP PICU. The patient had been to another OAP PICU for a previous acute admission, where they had had a bad experience. When told what was happening to them, the patient became “disturbed and aggressive” towards the staff because they did not want to go.
2.1.4 At this point the staff physically restrained the patient, who was “handcuffed” in preparation for a secure ambulance transfer. The ambulance was already on site and the ambulance staff collected and transferred the patient in handcuffs to the OAP. When arriving at the OAP PICU, the patient was stripped of all their clothes and personal belongings (including their mobile phone), and given anti-ligature clothing (tear proof clothing that minimises the risk to patients of attempting to ligature) and locked in an “isolation cell”. The patient said: “It felt like I was in prison and had done something wrong.”
2.1.5 Ward staff at the acute hospital from which the patient was transferred (the sending hospital) had considered that the patient was “undertaking some risky behaviours”, but had not shown any signs that they wanted to self-harm or die by suicide. The patient said: “I didn’t understand why I had to wear the clothes [antiligature] because I’ve never thought about dying like that [by ligature].” They said: “No one listened to me, when I said there was no need for this.”
Parent’s reflections
2.1.6 The parent of the patient found out about the transfer to the OAP 24 hours after the patient had been taken there. They were very angry, scared and anxious for their child because of previous OAP experiences. They immediately contacted the OAP and arranged a visit. They observed their child in a locked cell, with minimum access to an outside space, “heavily sedated, confused and very scared”.
The parent knew that their child needed routine, a calm environment and access to their mobile phone to call the parent. Their mobile phone was vital and a way for the patient to stay connected to their parent, grounded and safe. The parent complained to the OAP PICU but did not feel that they were being listened to. They kept complaining for several days until finally they reached out to a “kind and caring” staff member at the sending hospital. This staff member made a personal effort to visit the OAP PICU and found that the patient’s welfare and treatment needs were not being met. With a doctor from the sending hospital they assessed the patient and repatriated them (brought them back to the sending hospital).
3.1.2 All mental health staff and national leaders recognise that the best place to care for someone, and least restrictive, is in their own home or place of residence. NHS England told the investigation that only the most unwell people should be admitted to acute care.
3.1.3 The ‘Mental Health Act 1983: Code of Practice’ (Department of Health 2015) states that ‘NHS commissioners and providers should work together … to place individuals as close as is reasonably possible to a location that the patient identifies they would like to be close to (e.g. their home or close to a family member or carer)’.
3.1.10 NHS trusts and community mental health teams told the investigation that they are under significant pressure and that they cannot always apply the NHS England’s policies that are intended to reduce OAPs. This was because they have an increased service demand and usage and do not always have the time, capacity or ability to make the changes needed.
3.1.11 The investigation found that there is a gap between what senior policy makers believe is happening to reduce the use of OAPs and what is happening at the operational level.
3.1.15 Families and carers told the investigation that even an OAP 25 km away could be difficult, especially when they were working or the OAP hospital only gave very defined times to visit. Some families said that OAPs could be in a rural location with no access by public transport. One family told the investigation that they had a 2-hour drive to the OAP where their daughter was, but on several occasions when they visited within the time allotted, their daughter was not able to see them because she was unwell and they had to forgo the visit. Some other reasons that the family gave for short notice visit cancellations were “not enough or the right type of staff to support the visit” and they felt that the “needs of the organisation was being put ahead of the needs of their daughter”. There was no flexibility from the OAP hospital to allow a visit outside the set times. This meant they were unable to see their daughter for another week. This caused significant distress to the family and their daughter.
3.1.16 One trust told the investigation that it covered three local authority regions with two integrated care boards (ICBs) and had several acute wards across the whole region. A patient could be admitted to an acute ward at the far reaches of the region, in some cases up to 80 km from their home, that had poor transport links for visiting families. This was not considered an OAP as it was a bed within the trust and did not have to be reported to NHS England; however, this was locally referred to as an “internal OAP”. The trust had recognised that for the patient it was not close to home, so treated it as an OAP.
3.1.17 NHS England told the investigation that people with diagnosed learning disabilities or autism (neurodevelopmental conditions) are managed under specialised commissioning arrangements. NHS England and staff in acute settings told the investigation that there were not always specialist beds available locally for this group of patients and therefore many need to be sent to an OAP (NHS England, n.d.b). The investigation did not look at these specialised commissioning arrangements as they were out of scope for the investigation. The investigation did explore the impact of early diagnosis of neurodevelopmental conditions and the impact on OAP (see section 4).
3.2.2 Harm from OAPs can be difficult to define or even recognise. In some cases it leads to physical harm such as self-harming behaviours or attempting to die or dying by suicide. Patients, carers, family members and staff told the investigation that harm mainly manifests itself as distress, feeling scared, anxiety, developing complex post-traumatic stress disorder or other unsafe behaviours, among other mental health problems. The investigation heard that harm due to being sent to an OAP can be caused by the increased anxiety of not knowing new staff, or delays in discharge due to lack of capacity in social care or lack of social housing provision.
In an OAP, many patients said that they did not know the local environment and were “torn” from their social support network. This subject will be explored further in the HSSIB investigation ‘Creating conditions for learning from deaths and near misses in inpatient and community mental health services’.
3.2.3 Carers and families described the moment that their child was sent to an OAP as “devastating”. One parent described her child being collected by secure ambulance:
3.2.7 When a patient transferred between an OAP and their sending hospital, staff told the investigation that “they start different treatment plans, have their treatment altered and it’s almost as if the clock restarts [for their inpatient care]”. This costs more to the NHS, extends treatment and harms patients. They said that the longer a patient stayed in hospital the more likely they were to be readmitted at some point in the future. NHS trusts told the investigation that longer stays meant that patients could lose social skills and become less independent, becoming more reliant on care from the NHS and more likely to return as an inpatient.
Staff view on harm
3.2.8 Staff at all sites visited told the investigation that when discharge was delayed, patients could “end up in a spiral” of deterioration and suffer a relapse in their mental health. When this happened, staff told the investigation that any discharge plans were stopped, and in some cases had to start again, while the patient was treated for their relapse. This in turn meant beds did not become available and increased the chance of another patient being sent to an OAP.
“If we can’t discharge [patients] we have to use out of area placements.”
Challenges in discharge from an OAP due to patients now being lodged in a different local authority area from their normal place of residence.
3.2.11 The investigation observed people being cared for in various inpatient settings at NHS trusts and independent providers. These places can be challenging environments and staff told the investigation it can cause harm, particularly for those people who no longer need acute care when their discharge is delayed. The investigation found that OAPs can increase patients’ length of stay in hospital and therefore contribute to harm to patients.
A patient who relies on close relationships with family and friends to keep them well may see an OAP as inappropriate.
3.3.6 The Mental Health Act 1983: Code of Practice (Department of Health, 2015) states that placement of people ‘should take account of any risk assessment undertaken, the availability of services which can meet the patient’s individual needs, any assessment in respect of the likely duration of the patient’s stay, and any other factors raised by the patient and their family’.
3.3.9 ‘Acute inpatient mental health care for adults and older adults’ (NHS England, 2023a) provides guidance to integrated care systems (ICSs) and acute trusts ‘to support the commissioning and delivery of timely access to high quality therapeutic inpatient care, close to home and in the least restrictive setting possible’.
3.3.11 Staff responsible for bed management told the investigation that they did not consider personal choice, mainly because of time pressure and the sheer volume of patients they had to manage. One staff member told the investigation that an unwritten “next bed available for the next patient who becomes unwell” policy was in place. The investigation found that this was a common situation across many NHS trusts and recognised that this was due to pressures relating to patient flow and discharge.
3.3.13 The investigation found that parents, families and carers are not listened to and their views are not taken into consideration when making decisions on whether an OAP is the right thing for a patient or not. Many told the investigation that they believed that their voice was important in all care decisions made on behalf of patients, and that those decisions should be documented.
3.3.14 The Care Quality Commission (CQC) is responsible for monitoring and regulating healthcare, including how services are delivered in line with the Mental Health Act. The CQC told the investigation that when it visited patients, they were already in an inpatient setting and the CQC’s focus was on the care that was being provided, irrespective of whether in an OAP or not. It told the investigation that it did not assess or inspect a patient pathway, so would not look at the decision making process for sending a patient to an OAP.
3.3.15 The CQC said that it did not check whether patient and family and carers’ concerns and opinions were considered as required under the Mental Health Act. It told the investigation that it had not seen people’s choices documented with respect to OAP, but recognised that the Mental Health Act required that they be taken into consideration. The CQC said that at the point of admission, a patient is so unwell that they just need acute care, and even if a patient had previously said they did not want an OAP, it may be the only option open to healthcare staff to keep the patient and others safe.
3.3.16 The CQC told the investigation that:
“It is important to remember that the point of the MHA [Mental Health Act] is to provide a legal framework around compulsory admission, assessment and treatment. This means that decisions about care and treatment under the MHA can be made, lawfully, to which people do not consent. By definition, therefore, it is lawful, at times, for providers to make decisions relating to care and treatment under the MHA which do not reflect the wishes, preferences or views of people using services, their carers or families. People’s wishes and preferences should be documented but the MHA allows them not to be complied with in relation to decisions where the Act gives clinicians the power to admit or treat without consent.
Safety recommendation R/2024/042:
HSSIB recommends that the Department of Health and Social Care includes the documenting of patient, family and carers’ wishes and preferences within the Mental Health Bill. This will ensure all patient, family and carer voices are considered in decisions relating to where the patient identifies they would like to be close to, for example the patient’s home or a family member, specifically when an out of area placement is needed.
3.4.1 Many NHS trusts that the investigation visited said that when they had to use an OAP they considered the latest CQC rating before sending a patient to an independent mental health provider. They looked for a CQC rating of ‘good’ or ‘outstanding’; however, if there was no bed availability within these ratings they would consider providers rated as ‘requires improvement’ (Care Quality
Commission, 2022). Several NHS trusts said that to accept an OAP place in a ‘requires improvement’ OAP they would visit to assess the placement themselves before a decision was taken so that they could assess whether they “feel comfortable” with sending patients there. They also said that under no circumstances would they consider sending a patient to an OAP provider rated as ‘inadequate’.
THIS IS NOT TRUE FOR EXAMPLE:
The investigation reviewed CQC ratings for several of the independent OAP providers that NHS sending hospitals used. They ranged from reports published in early 2024 (most up to date) to over 3 years since the last inspection. Therefore sending hospitals may be basing decisions on which OAP to use on out of date information.
The sending hospital themselves might need an updated CQC rating.
A consultant psychiatrist in an OAP hospital told the investigation that they were responsible for the treatment plan of patients who were at an OAP. They said that they would update NHS colleagues when they were able, but this would only be when the patient was getting ready for discharge.
3.4.9 A social worker within an ICB told the investigation that the ICB was “KPI [key performance indicator] focused, and only maintained oversight on learning disability and autism [patients’] out of area placements”. They said that under guidance from NHS England (2023b), the ICB had a responsibility to monitor people with a learning disability and/or autism who were sent to an OAP. The social worker said that ‘commissioner oversight visits should be happening at least every 8 weeks for adults and every 6 weeks for children and young people’ (NHS England, 2023b).
The investigation found that the same arrangements or requirements do not exist for inappropriate OAPs.
Cygnet Appletree GP – 1-463761234 Cygnet Appletree (20/01/2023) INS2-14022377821 Suddenly rated Good!! Very strange rating indeed especially since RT appeared frequent from what I heard in 2023: The CQC’s report said staff rarely attempted to calm patients down before resorting to physically restraining them and injecting fast-acting tranquilisers, which were “used frequently without clear rationale”. That was an accurate description from what I have heard in 2023.
Care Quality Commission (CQC) inspectors found Cygnet Appletree in Meadowfield, Durham, had not protected patients “from abuse or poor care”. Following the April inspection, it restricted the hospital from taking new patients without prior written consent. However the Doctor there Dr M had the decency to contact me on one occasion to advise about an urgent A&E admission. However RT is documented as being frequent.
Cygnet Appletree: Mental health hospital ‘did not protect patients’ – …
http://www.bbc.com/news/uk-england-tyne-58323174
Cygnet Hospital Godden Green in Sevenoaks shuts …
Another one above and that didn’t stop the bed management!
3.4.11 Several ICBs told the investigation that they did not maintain oversight of inappropriate OAPs. They said this was the responsibility of the sending hospital.
They said that they requested information from NHS trusts on OAP figures and costs to try to reduce OAP spending.
Advocacy
3.4.12 Many patients do not have a social support network. This might be because there has been a breakdown in their relationships, they do not have anyone to care for them, they are in social care, or many other reasons. This is not true in our case.
People without a social support network may have to rely on advocacy services to speak for them after they are admitted as an inpatient. Unfortunately NOT ALL ADVOCATES CAN BE TRUSTED.
Advocates are trained in objectively representing the views of people who otherwise cannot speak for themselves. Unfortunately in reality this does not appear to be true when confidentiality has been breached.
Many patients who are placed outside their local area are uncomfortable, feel vulnerable and need someone to speak on their behalf.
3.4.14 The charity VoiceAbility told the investigation that IMHAs help patients to voice their concerns when they are unable to do so by themselves. This is particularly relevant when there are “scary” large meetings with lots of people, such as a multidisciplinary meeting. VoiceAbility said that there are “advocacy deserts” across the country and real variability in how patients are told about advocacy. It said that its work had identified that many patients were told about advocacy when they were at their most vulnerable and unwell, when they may not be able to process information or make decisions. It said that a patient’s decision at that point was rarely revisited to see if the situation had changed. Still waiting for response from Voiceability to my valid complaint.
3.4.19 Several NHS trusts told the investigation that it was easy to see patients as a “commodity” rather than as a person: “they need a bed so get the next bed”. They said that they are “trying to do their best for patients” but the “sheer volume and increasing acuity [more co-existing social and mental and physical health conditions]” of patients means they are “forced” to manage people as a “commodity” despite it going against their instincts.
3.4.20 NHS trusts told the investigation that the average cost of a patient on an NHS acute ward was approximately £400 per day. They also told the investigation that the cost of sending a patient to an independent provider for an OAP could range from £600 to £1,000 per day depending on the site and the needs of the patient. The cost in both settings may increase or decrease depending on the patient’s treatment plan or the number of staff needed to keep an individual patient safe.
3.4.21 Senior NHS trust staff told the investigation that they did not need more beds, they just needed the health and social care system to operate more efficiently and collaboratively to improve patient flow and discharge.
3.5 Mental health inpatient flow
3.5.1 Many mental health and social care staff told the investigation that when describing OAP, it was impossible to look at the healthcare inpatient system in isolation. Many patients needed acute services because the lack of appropriate provision of community mental health care, social care support, drug and alcohol services, or delayed diagnosis of neurodevelopmental conditions, meant their needs had not been met to keep them safe in the community.
Multi-agency meetings
3.5.5 The investigation observed several multi-agency discharge events (MADEs).
These are meetings where individual patients are discussed and discharge planning is carried out. The meetings are chaired by the NHS trusts and should be attended by community mental health teams, doctors, nurses, psychologists, therapists, and representatives from ICBs and local authorities (LAs). The meetings are meant to be multi-agency, but the investigation observed that in several cases only staff from the acute trust and community teams attended. As these teams were within the acute trust’s resources, or worked very closely with them, they were easy to coordinate and bring to the meeting. NHS trusts chairing the meetings told the investigation that the external agencies were outside the trusts’ control and would only attend if they had someone available to do so. LA social workers said they were stretched and often had competing priorities so couldn’t always make the meetings. Similar reasons were given by ICBs.
3.5.6 The lack of full multi-agency attendance at the MADE meant that discharge planning could not be completed, and many actions were left unresolved. This had a direct negative impact on flow and discharge, and staff told the investigation that it was another reason for the need for OAPs.
3.5.10 The Royal College of Psychiatrists (2022) sets standards for crisis resolution and home treatment teams. One of these standards states:
‘The team works closely with acute inpatient care, including gatekeeping and facilitating early discharge.
Safety observation O/2024/044:
Crisis resolution and home treatment teams can improve patient safety by joining quality networks for crisis resolution and home treatment teams and could consider using continuous clinical reviews of mental health acute inpatients. This can ensure that appropriate patients are discharged early and could maximise acute care bed availability for patients in the community who are at high risk because of their mental health problem, and reduce the need for out of area placements
3.6 Discharge from mental health inpatient settings
The discharge challenge
3.6.1 Every NHS trust the investigation spoke with described discharge as the most significant challenge and driver for the use of OAPs. They said that if discharge could be addressed “systemically” then flow would improve and the use of OAPs would be reduced. All NHS trusts and OAP providers told the investigation that the most significant factor preventing timely discharge was the lack of health and social care integration and collaborative working. NHS England told the investigation that challenges relating to discharge had an impact on flow through the system and could create additional harm to patients, as previously mentioned in this report.
3.6.4 Senior NHS trust staff told the investigation that healthcare’s job was to treat patients who were acutely unwell and then discharge them and hand over their care to social care services. They said that from their perspective, once a patient was well enough to be discharged, and if they needed a social care package or housing, then the patient was social care’s or an LA’s responsibility. One NHS senior leader told the investigation that there were “differences in purposes [between health and social care], but when the differences can’t be resolved by one side or the other it is the patients who come to harm”.
3.6.6 The Department of Health and Social Care (2024b) produced guidance on how NHS bodies and local authorities should work together to assist with discharge planning. It sets out eight principles, that if followed may ensure more efficient discharge for acute patients. The principles are:
3.6.7 Although not specifically referred to in this report, the investigation discussed most of the principles above, and found that in practice the principles were not easy to achieve. NHS staff, independent OAP providers and local authorities told the investigation that the main challenges to complying with the principles were the different funding models, governance structures, business processes andregulations between health, social care and local authorities. These could slow down the discharge process, extend stays for patients and increase the reliance on OAPs.
principle 1: individuals should be regarded as partners in their own care throughout the discharge process and their choice and autonomy should be respected. This is not happening!
principle 2: chosen carers should be involved in the discharge process as early as possible. Very true! and not cut out of everything.
principle 3: discharge planning should start on admission or before, and should take place throughout the time the person is in hospital. Definitely not happening after so many years!
principle 4: health and local authority social care partners should support people to be discharged in a timely and safe way as soon as they are clinically ready to leave hospital
principle 5: there should be ongoing communication between hospital teams and community services involved in onward care during the admission and post discharge Not happening.
principle 6: information should be shared effectively across relevant health and care teams and organisations across the system to support the best outcomes for the person good communication is required for this.
principle 7: local areas should build an infrastructure that supports safe and timely discharge, ensuring the right individualised support can be provided post discharge No sign in sight and absolutely nothing safe
principle 8: funding mechanisms for discharge should be agreed to achieve the best outcomes for people and their chosen carers and should align with existing statutory duties.
3.6.7 Although not specifically referred to in this report, the investigation discussed most of the principles above, and found that in practice the principles were not easy to achieve. NHS staff, independent OAP providers and local authorities told the investigation that the main challenges to complying with the principles were the different funding models, governance structures, business processes and regulations between health, social care and local authorities. These could slow down the discharge process, extend stays for patients and increase the reliance on OAPs.
3.6.8 ‘Discharge challenge for mental health and community services providers’ was published by NHS England (2022). The guidance gives 10 steps that should be followed to assist with OAP discharge. NHS England had seen many of these 10 steps being applied locally but providers cannot influence LAs where actions can only be carried out by an LA. NHS trusts told the investigation that they were trying to comply with the guidance but found it challenging to do so when LAs and ICB partners did not attend meetings or had different priorities and perspectives on how patients should be cared for (on discharge). Many of 10 the steps rely on the advice of system partners, but NHS trusts have no ability to influence them. They told the investigation that healthcare providers were left with patients who were ready for discharge and who did not need to be in the challenging environment of an acute ward for prolonged periods.
3.6.10 The trust also said that dealing with several LAs and ICBs took significant management focus and they encountered different ways of working, priorities and financial arrangements, making discharge planning “very difficult”.
Funding
3.6.12 The ‘Close to home’ report (National Development Team for Inclusion, 2020) found that in relation to discharge and funding, ‘funding challenges are exacerbated by different systems growing and being affected by separate national legislation and guidance, rather than a national, integrated approach to planning’.
3.6.16 The investigation heard frustration from NHS trusts, ICBs and LA staff about the way finances are organised. They said that there were not common “business processes” due to the way that each of the organisations were governed and who they were accountable to. It was described that when the NHS needed to fund temporary accommodation to support discharge when the LA could not provide social housing, assigning the money from NHS funds could be relatively simple within the governance rules that exist. They said that the same funding “simplicity” did not exist with LAs, which meant it took longer to make decisions about allocating money for housing needs.
Social housing and temporary accommodation
3.6.17 LA social workers told the investigation that finding patients suitable social housing, or having their current social housing repaired before they are discharged, is a significant challenge and can take “some time”. It may mean that the discharge timelines that the NHS staff are working to cannot be met. The investigation learned that some patients had been in hospital for so long that they had lost their rights to keep the same social housing, so needed to find a new property before they could be discharged. NHS staff told the investigation that they could not, or would not always be willing to, discharge a vulnerable person to no address.
3.6.18 LA staff told the investigation that they knew that people needed social housing or social support packages to support discharge. They said that “bureaucracy” and “funding panels” (meetings where money is assigned to specific tasks) meant accessing funds could be slow and that some cases needed extra scrutiny with an additional funding panel. This process could take up to 12 weeks, which could mean significant delays in discharging patients from acute or PICU settings who were ready for discharge. Social workers said that they were “stretched thin” and they not only had to manage mental health patients awaiting discharge but other people who needed social care support. Many said that they felt there were “too many competing priorities” which meant that their focus could not always be given to mental health patients. They also said that there were staffing challenges within social work which meant that there were not always the staff to undertake assessments before discharge.
3.6.19 One NHS trust told the investigation that it had tried to be innovative and resolve the use of OAP and improve inpatient flow by discharging patients to bed and breakfasts funded by the trust. It said that when a patient was ready for discharge and the LA was unable to support a social housing request in the timeframe needed by the acute ward, the trust was able to fund a place in local bed and breakfast accommodation. The trust said that the cost of bed and breakfast accommodation was approximately £100 per night, compared to £400 per night on its ward. This approach also freed up a bed for a new patient and improved flow.
The trust said it had to take these steps because the LA was unable to meet the NHS trust’s timeframes for discharge. The investigation was told that this initiative was funded by the NHS trust despite the patient being ready for discharge and seen as “not the trust’s responsibility anymore”. The trust told the investigation that this had “helped improve discharge, flow, reduced use of OAP and helped prevent unneeded extended stays in hospital”.
Safety observation O/2024/045:
Health and social care organisations can improve patient safety by working together and embedding mental health social workers from the local authority in mental health acute hospitals. This can ensure that patients’ holistic health and social care needs are considered throughout their acute mental health admission and on into the community, and improve efficiency of working, patient flow and discharge and reduce the use of out of area placements.
One senior ICS member told the investigation that the ICS was a “fractured system, built on relationships rather than framework”. Another said there was “not a shared funding model” which meant that there were significant competing priorities and therefore lack of common patient safety focus in the system.
3.6.30 The investigation found that there was variation in how ICSs operate. The Department of Health and Social Care told the investigation that the Health and Care Act 2022 and guidance on ICSs were written in a way that allowed variation to meet the needs of local communities. Many staff in ICSs told the investigation that they understood the purpose of their organisations, but were not given clear guidance on how to set their organisation up. This had allowed inconsistencies and variability to develop across the country.
Safety recommendation R/2024/043:
HSSIB recommends that the Department of Health and Social Care works across government to review the statutory instruments, business processes and regulations that govern mental health services, social care and housing services impacting on mental health out of area placements and creates a proposal for the future accountability and integration of health and social care. This is to ensure that they are operating to consistent statutory, financial and regulatory frameworks. By addressing system integration and collaboration between health, social care and local authorities will define accountability and reduce or prevent out of area placements.
Healthcare staff working together
4.1.16 NHS trusts told the investigation that all teams needed to work together with patients to allow treatment plans to work and ultimately help patients get better and be discharged. This included community teams, home treatment teams, acute ward staff (including doctors, nurses, psychologists, therapists, health care assistants (HCAs), and hotel services staff). Several consultant psychiatrists told the investigation that if the whole multidisciplinary team and LA social workers did not work together in a manner that benefits the patient, safe flow and discharge became very difficult.
4.1.18 Many nurses and psychologists told the investigation that while HCAs’
primary purpose when undertaking observations was to watch patients to ensure their safety, if they engaged in a meaningful way with patients it could significantly benefit patients and could reduce lengths of stay.
4.1.20 While the investigation was not specifically exploring inpatient treatment and care, the investigation found that where patients are engaged in meaningful activities by caring and interested staff, it can benefit patients. This could result in reduced lengths of stay (Psychological Professions Network, 2024), improve patient flow and aid discharge.
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