Our investigation explored what drives the need for out of area placements, and the impact on patients and families when they are placed far from their homes. Through focus groups, one-to-one conversations and site visits, HSSIB heard examples of harm ranging from anxiety, physiological stress, post traumatic stress disorder, and sadly cases of patients dying by suicide. Patients and their families also told HSSIB their experiences had led to anger, frustration and loss of trust in the mental health system.
When referring to out of area placements, our report only considered those that are inappropriate – where a patient is unable to be cared for in their local area and has to be sent to an alternative mental health provider. Our investigation did not look at appropriate placements i.e. when a person needs to access a specialist service not available in their area.
Key findings
Some of the key findings in relation to patients and families include:
- Patients, families and carers rarely want an out of area placement and their choice and opinions are not always taken into consideration when decisions about out of area placements are made.
- 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 monitored during Care Quality Commission inspections.
- Out of area placements can increase patients’ length of stay in hospital and therefore contribute to harm to patients.
- 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 investigation emphasises that the issue of out of area placements is complex. National organisations told investigators they may be the only option for someone who is acutely unwell when no bed is available in their local hospital. This is preferable to someone remaining unwell and potentially unsafe in the community. The report says there is a ‘national ambition’ to reduce the use of out of area placements, and prior to the Covid pandemic, the government had set a target to eliminate inappropriate out of area placements by 2021. However, data showed overall out of area placements are steadily increasing – in March 2023 there were 793 placements and a year later in March 2004 there were close to 900 across England. Of the 900, 805 were inappropriate.
Reasons for out of area placements
HSSIB identified a number of reasons for the NHS using out of area placements and explores them in detail in the report.
The most significant factor we identified in relation to system conditions was the challenges of system integration and collaborative working between health and social care. Our report says the mental health inpatient system cannot be looked at in isolation – a patient’s care will cross into other services such as community mental health services, social care and social housing provision by local authorities. We emphasised that the NHS and local authorities have rules, governance, legal frameworks, financial commitments that differ and this can create ‘friction’ in the system. This prevents integration and pooling of funds across organisations, slowing down discharge and patient flow.
The report concludes with two safety recommendations. The first is aimed at ensuring patients, families and carers wishes and preferences are considered when decisions about care are made. The second safety recommendation is aimed at reducing or preventing out of area placements by improving integration and collaboration between health and social care.
Investigator's view
Neil Alexander, Senior Safety Investigator at HSSIB, says: “The reality is patients need to be treated and sometimes it is seen as safer to admit them to an inpatient ward or unit. However, as our investigation sadly showed, the harm caused to patients when moved far from home or moved back and forth between settings can be distressing, for them and for their families. Throughout our investigation, we heard troubling experiences from patients and their loved ones, with many feeling they were not listened to and their needs and wishes not taken into consideration. Staff working across inpatient settings shared their concerns over patient harm, and the impact of delayed discharge.
“The investigation emphasised that inappropriate out of area placements are a symptom of wider issues within health and social care – financial and resources pressures, long waiting lists for social housing and a lack of true integration between the two. The findings of our investigation were not a surprise to those working in mental health care, and it is clear that urgent improvements need to be made to reduce the use of inappropriate placements and reduce harm. Patients, families and carers should feel that safety and wellbeing is a priority and that they are involved in care decisions – placements in mental health care should not leave people scared or traumatised.”
Patient, family and staff quotes in the report
- Pages 17-19 set out a patient and parent experience of an out of area placement. The patient said “being taken away in the middle of the night, in handcuffs, and no one explaining to me why caused PTSD.” The parent said that “no one was there for my child, [they] had no choice and were treated like a criminal”.
- During the investigation, one parent told HSSIB “my daughter was escorted out to the ambulance by people she didn’t know, wearing dark threatening clothes, almost like military. She was clutching her teddy to her chest and looked so small and frightened.”
- One patient commented on the distance from their family saying “I’m not able to see my family as they can’t afford to travel from the north of England [to the south]. I really miss them and it makes me sad.”
- A staff member told HSSIB “Every day not needing to be in hospital is a day of harm we are causing.”
