Mental health inpatient settings: out of area placements

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.

This report examines the reasons for OAPs, the harms caused by them and how patients can be kept safe if an OAP is necessary. In particular it focuses on inappropriate OAPs. These are where a patient is unable to be cared for in their local NHS mental health acute inpatient setting and has to be sent to another, normally independent, mental health provider for ongoing treatment and care. These OAPs can be significant distances from a person’s residence. The investigation recognises that other OAPs exist for specialised commissioned services such as those for patients with eating disorders, but these were not considered in this investigation. The investigation has been informed by work carried out in the other investigations in the series, in particular ‘Creating conditions for learning from deaths and near misses in inpatient and community mental health services’ and ‘The provision of safe care during transition from children and young person to adult, inpatient mental health services’.

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.

There are many factors that drive the need for the NHS to use inappropriate OAPs. This investigation focuses on the most significant factors, including patient flow through the inpatient setting, discharge from inpatient settings and challenges relating to integration and collaborative working between health and social care.

Relating to patient, family and carer experiences

• 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.
• Patients, families and carers rarely want an OAP and their choice and opinions are not always taken into consideration when decisions about sending someone to an OAP are made.
• 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.

Relating to conditions in the health and care

• There is a national drive to reduce OAPs, but there continues to be an increasing trend in their use.
• OAPs may be the only option for patients if they are acutely unwell and need admission to inpatient services and there are no beds available in their local NHS mental health hospital. If OAPs are not utilised in this situation, people will remain unwell in the community and potentially present a high risk of harm to themselves or others.
• 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 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.

HSSIB makes the following safety recommendations

HSSIB makes the following safety observations

1.1.1 This investigation focuses on inappropriate out of area placements (OAPs) for mental health inpatients in England. OAPs can cause harm or can be a benefit to patients, depending on their individual circumstances. OAPs can be used for different purposes:

• When a patient needs a specialised service and that service is not available locally – in the report these are referred to as ‘specially commissioned OAPs’.
• When there are no acute mental health beds available in a patient’s local mental health hospital – this is what the healthcare system describes as an ‘inappropriate OAP’ and these will be referred to throughout the report as ‘OAPs’.

1.1.2 OAPs are normally provided by an independent mental health provider, and as the term alludes to is when a patient is sent to a mental health provider that is often a significant distance from the patient’s home.

1.1.3 Specially commissioned placements are a necessity for some patients. These can include placements for eating disorders or for learning disabilities and autism in children and young people (NHS England, n.d.a). The investigation recognises that for these patients, if there are no local beds available, they may need to be sent to an OAP. The effects of going to a specially commissioned OAP may be the same as those experienced by patients who are sent to an inappropriate OAP, depending on individuals’ personal circumstances. The safety recommendations and safety observations made in this report are equally as valid for all people who are sent away from their local area, no matter what the reason.

1.1.4 There have been various initiatives throughout England to try to reduce OAPs, but there is variation across England in the management of patients in an OAP.

1.1.5 Patients in secure mental health inpatient settings, that are as a result of diversion from the Criminal Justice Service, are not considered in this report.

1.1.6 Throughout the report, the following terms are used for ease of reading:

• ‘Patient’ – describes a person who has used or is using mental health services This is in line with recent NHS documents (NHS England, 2024a). The report refers to people who experience a ‘mental health problem’ in line with Mind (2020) (see 1.2.1).
• ‘Acute’ – an acute mental health setting.
• ‘Sending hospital’ – an acute mental health hospital that sends a patient to an OAP.
• ‘OAP provider’ – normally an independent mental health service providing acute mental health services similar to those provided by the NHS.
• ‘Social housing’ – this refers to Section 117 supported accommodation (see 1.4.2).
• ‘Repatriate’ – when a patient is returned from an OAP to their sending hospital.

1.2.1 A person’s mental wellbeing/health influences how they feel, what they think and how they behave (World Health Organization, 2022). Around a quarter of the population of England will experience a ‘mental health problem’ each year (Mind, 2020). A mental health problem is a disturbance of a person’s mental wellbeing that impairs their ability to function as they would do normally. Most people experiencing a mental health problem will be cared for outside of hospital in the community. For some people admission to hospital on a voluntary or compulsory basis is needed. A hospital admission may be used to help protect people from hurting themselves and/or others.

1.2.2 The Mental Health Act (1983) is the main legislation that covers the assessment, treatment and rights of people experiencing a mental health problem in the community and in hospital. Where a person is admitted to hospital on a compulsory basis they may be described as ‘detained’ or ‘sectioned’ under the Mental Health Act. The Act is split into different sections which contain information about being detained against a person’s wishes, treatment while detained and the allowance of ‘leave’ from hospital for an agreed purpose and period (this is often referred to as ‘Section 17 leave’). At the time of writing reforms to the Mental Health Act were being considered.

Mental health inpatient care

1.2.3 In England, there are different types of mental health inpatient services. This investigation focused on inpatient services for children and young people and adults who experience mental health problems that require immediate (acute) care. The demand on mental health inpatient services in England is high and has been increasing. Between 2016 and 2023 there was a 24% increase in the number of patients in hospital (The King's Fund, 2024). Bed occupancy has consistently been above the recommended maximum of 85% (except during the COVID-19 pandemic) since 2010/11 (Mental Health Watch, 2024).

Acute adult mental health inpatient wards

1.2.4 Adult acute inpatient wards provide care to adults experiencing the acute phase of a mental health problem. Wards may have a specialist focus, such as caring for older patients. Certain wards, called psychiatric intensive care units (PICUs), provide care to patients who are more unwell. Care includes medical, nursing and therapeutic services.

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).

1.3.1 The Department of Health and Social Care (2016) released the following guidance in relation to OAPs:

‘The government has set a national ambition to eliminate inappropriate out of area placements (OAPs) in mental health services for adults in acute inpatient care by 2020 to 2021. This definition of OAPs has been developed following significant stakeholder engagement to enable progress against the ambition to be monitored. It is aimed at providers, commissioners and users of local adult inpatient acute services in England.

‘It is intended to support providers and commissioners in accurately monitoring and reducing their use of OAPs and to help providers submit accurate information on OAPs to national data collections. It will also be of interest to those using mental health services and who may be placed out of area for their care.’

1.3.2 The guidance goes on to provide an out of area placement decision tree (see figure 1).

Figure 1 Out of area placement decision tree (Department of Health and Social Care, 2016)

1.3.3 The guidance describes circumstances where it may be appropriate to use an OAP:

• ‘the person becomes acutely unwell when they are away from home (in such circumstances, the admitting provider should work with the person’s home team to facilitate repatriation to local services as soon as this is safe and clinically appropriate)
• there are safeguarding reasons such as gang related issues, violence and domestic abuse
• the person is a member of the local service’s staff or has had contact with the service in the course of their employment
• the decision to be treated out of area is the individual’s choice e.g. where a patient is not from the local area but wants to be near their family and networks’. (Department of Health and Social Care, 2016)

1.3.4 NHS England (2024c) defines (all) out of area placements as:

‘A person with assessed acute mental health needs who requires adult mental health acute inpatient care, is admitted to a unit that does not form part of their usual local network of services. By this we mean an inpatient unit that does not usually admit people living in the catchment of the person’s local community mental health service, and where the person cannot be easily visited regularly by their care co-ordinator to ensure continuity of care and effective discharge planning.’

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.

1.3.6 NHS England provides guidance which states that one of its priorities is to ‘improve patient flow and work towards eliminating inappropriate out of area placements’ (NHS England, 2024d).

1.4.1 Several terms that are used repeatedly in this report have their origins in statute.

1.4.2 The Mental Health Act 1983: Code of Practice (Department of Health, 2015) sets out the law in relation to mental health. Various sections of the Act are mentioned in this report. They are:

• Section 2 – this allows for a patient to be detained to a mental health inpatient setting under the Mental Health Act for up to 28 days while an initial assessment is carried out. After 28 days the patient may be reassessed and detained under Section 3 for further treatment, or patients may be discharged and the Section 2 restrictions removed if clinicians assess this to be appropriate.
• Section 3 – this relates to patients who have been assessed by a healthcare clinician and detained to a mental health inpatient setting under the Mental Health Act. Some people can be detained directly under Section 3 on admission or some people can be detained under Section 3 after an initial detention under Section 2 (see above). The Section can last up to 3 months and can be reviewed, shortened or extended as necessary to allow discharge or further treatment.
• Section 17 – where a patient is granted leave under the Mental Health Act, either escorted or unescorted, with pre-set boundaries and timings to return. Decisions about whether leave is escorted or not and what boundaries are in place are normally made by a consultant physiatrist with the assistance of a multidisciplinary team.
• 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.
• Section 117 – this is the aftercare that a patient can be receive in the community when discharged from acute care. Aftercare can include health and social care support and supported accommodation provided by local authorities.
• Section 136 – this relates to taking a patient to a place of safety. The NHS and system partners (for example the police and local authority) refer to this place of safety as a ‘136 suite’ and patients can be taken there directly by the police, ambulance or community mental health teams or home treatment teams. Patients may also be transferred there directly from a hospital emergency department. 136 suites are normally located at NHS trusts. They are designed to keep people safe for short periods of time and until they can be admitted to an inpatient setting or be assessed and discharged.

1.4.3 One group of patients that is not covered under the Mental Health Act is informal patients. These are patients who are willingly and voluntarily admitted to a mental health inpatient setting because they recognise that they need help and treatment. They are free to leave the mental health inpatient setting at any time, unless staff believe they pose a threat to themselves or others. If this is the case they can be detained under the Mental Health Act for their own and others’ protection.

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).

1.4.5 The Mental Health Act 1983: Code of Practice provides statutory guidance to health and social care authorities and staff on how they should proceed when undertaking duties under the Act. It is prepared and published by the Secretary of State.

2.1.1 HSSIB spoke to many patients, families and carers. This section tells the story of one of these patients and their family. It demonstrates many of the factors relating to out of area placements (OAPs), and in particular the harm that can be caused not only to patients but to their families and carers.

2.1.2 The story involves a young adult patient who told the investigation about a “horrific” experience that they had been through.

Decision to use an OAP

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.

Transfer to the OAP

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 [anti-ligature] 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).

2.1.7 The parent said that the whole experience lasted for 8 days from transfer to repatriation, and was only resolved early because of the parent’s persistence and the goodwill of one NHS staff member. They said that the experience had traumatised their child and the fears of an OAP were always there and more acute than ever.

2.1.8 The parent said that “no one was there for my child, [they] had no choice and were treated like a criminal”. They said that no one was there to speak for the patient as they could not speak for themselves and that the parent’s voice was ignored throughout the experience.

Patient’s reflections

2.1.9 The patient told the investigation: “Being taken away in the middle of the night, in handcuffs, and no one explaining to me why caused PTSD [post-traumatic stress disorder].” The patient said: “I never want to go to an OAP ever again, and will do almost anything to prevent it happening.”

2.1.10 The investigation will consider many of the factors and concerns identified in the patient’s and parent’s experience in section 3 of this report.

3.1.1 There was a UK government aspiration for no inappropriate OAPs by the end of 2021 (Department of Health, 2016). NHS England told the investigation that the COVID-19 pandemic was a significant factor in not achieving this goal along with a focus on other areas of healthcare, such as elective recovery. NHS England said that since the pandemic there had been an increased awareness of mental health and that the people who were using the service had more complex needs than ever before. NHS England said that this had had an effect on treatment times and lengths of stay in hospital which had not been previously predicted, modelled or planned for. It said that this had also had an impact on the use of OAPs.

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)’.

3.1.4 NHS England and NHS trusts told the investigation that nearly all OAPs are at independent mental health service providers. This normally means that NHS trusts have to find an independent mental health provider at short notice to ensure that patients are in a ‘place of safety’ (as set out in the Mental Health Act 1983). Some NHS trusts told the investigation that they had developed localised techniques and policy for continuously monitoring patients in acute and community settings to improve flow and discharge, reduce use of OAPs and increase patient safety.

3.1.5 One of NHS England’s mental health priorities for 2024/25, as set out in its priorities and operational planning guidance (NHS England, 2024d), is to ‘improve patient flow and work towards eliminating inappropriate out of area placements’. NHS England told the investigation that the need for OAPs is one symptom of many other issues in the system including patient choice, patient flow through the mental health system, discharge from acute care, and health and social care integration and collaborative working.

3.1.6 NHS trusts told the investigation that of the people who use their services, most do not want an OAP. However, many NHS trusts said that they were “overwhelmed” by the number of people needing acute care and felt they did not have any option but to use OAPs. They said that if there are “no beds available, it is better for the patient to be sent to an OAP than remain unwell and unsafe in the community”. They recognised that these were difficult decisions but felt there “was no other choice”.

3.1.7 All of the patients that the investigation spoke with said that they did not get to choose whether to be sent to an OAP or not, and they were not asked what the potential impact of an OAP on them or their families and friends might be. This will be explored later in the report.

3.1.8 The investigation heard that in the majority of cases the reason for an OAP was lack of available beds, or a sending hospital’s lack of the appropriate bed. For example a female patient may need a bed in a psychiatric intensive care unit (PICU), but their local trusts PICU is for male patients only. Several NHS trusts told the investigation that they ran an all-male PICU; this could be adapted for a female patient if needed but if there was a concern about sexual safety, female patients may be sent to an OAP.

3.1.9 NHS England described tackling the use of OAPs by increasing community mental health services and increasing crisis and home treatment teams to prevent people from needing to be admitted to acute care. NHS England also described ongoing work into how crisis and home treatment teams could visit and assess patients in acute NHS mental health wards to assist with the early discharge of patients. An example of this will be explored later in the report.

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.

3.1.12 NHS England (2024c) statistics report that in the period 1 to 31 March 2024 there were 900 OAPs in England. NHS England told the investigation that of the 900 OAPs, 805 were inappropriate OAPs. Figure 2 shows HSSIB’s representation of this data.

Figure 2 OAPs in England, 1 to 31 March 2024

3.1.13 NHS England told the investigation that tackling OAPs was one of its priorities, but the data that it collects suggests that from March 2023 to February 2024 the numbers of OAPs increased steadily (see figure 3).

Figure 3 Number of OAPs in England, March 2023 to February 2024

3.1.14 Patients can be sent to OAPs that are a significant distance from their home. Many told the investigation that they were not able to go anywhere meaningful or familiar when granted day leave and families could not visit because of work or financial constraints. NHS England has reported on the distance that patients have to travel to an OAP (see figure 4).

Figure 4 Distances that patients travel to OAPs, 1 to 31 March 2024

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).

3.2.1 When harm occurs it can increase the acuity of patients (the severity of their symptoms and level of care they need) and extend lengths of hospital treatment. Galante et al (2019) found that:

‘OAPs are expensive, inefficient, distressing for patients, and may increase risk. We found that there were significantly increased lengths of stay, more subsequent contacts with services, and more self-harm in this group.’

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:

Many patients said that they were unwell and the sight of staff in what “looked like a prison van and prison officer type uniforms” and the way that they were transferred to an OAP, caused them great distress and anxiety on top of their existing mental health problem.

3.2.4 The investigation found that harm (psychological, distress and anxiety) was happening to patients, families and carers due to OAPs. There was also significant anger, frustration and loss of trust in the mental health system as a result of their experiences.

3.2.5 Some patients describe their experiences:

Patient who was returned to their NHS sending hospital after a period in an OAP

Patient who was returned to their NHS sending hospital after 10 weeks in an OAP

Patient in an independent OAP provider sent from an NHS hospital

Returning from an OAP to the sending hospital (repatriation)

3.2.6 The problem of building relationships and trust with staff in an OAP is further complicated when a patient is scheduled for repatriation to their sending hospital. The investigation asked whether patients were given a say in the decision to repatriate them, and some said they were involved in multidisciplinary team discussions, but ultimately the decisions were made by hospital staff. Staff told the investigation that decisions about repatriation were made based on financial considerations, and patient choice was a low priority in those decisions. Staff said that there could be pressure from ICBs and NHS trusts to repatriate patients, even if the patient was doing well in the OAP.

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.

3.2.9 Some quotes from staff are below:

3.2.10 NHS England told the investigation that patients sent to OAPs generally had longer hospital stays (Crossley and Sweeney, 2020). Several NHS consultant psychiatrists said that there were many reasons for extended stays as mental health inpatients, but the main factors were:

• lack of continuity of care between the sending hospital and the OAP provider
• challenges in discharge from an OAP due to patients now being lodged in a different local authority area from their normal place of residence
• clinicians in the OAP may have a different view on a treatment plan to those in the sending hospital and if repatriated sometimes the sending hospital has to develop and start a different treatment plan
• lack of patient oversight from the sending hospital while at an OAP because the patient is now the OAP doctor’s responsibility.

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.

HSSIB makes the following safety observation

3.3.1 The investigation spoke to many current patients, past patients and those caring for people who have used mental health services. People’s individual experiences of using mental health services can be very different, as can their experience of OAPs.

3.3.2 The investigation heard from patients that most people do not want to be in an OAP. Patients that the investigation spoke with fell broadly into three categories relating to OAPs:

• those who do not want to be in an OAP
• those who neither want or do not want to be in an OAP
• those who prefer to be in an OAP.

3.3.3 Which broad category patients fell into very much depended on individual circumstances, including social or family/community circumstances. Below are some simplified examples of real patient experiences; however, the investigation spoke to patients who had many combinations of the situations below, along with other complexities in their life:

• A patient who relies on close relationships with family and friends to keep them well may see an OAP as inappropriate.
• A patient who has had a challenging social background may not want to be cared for near their place of residence, and an OAP may be appropriate as it removes them from harmful relationships.
• Patients who do not have close relationships at their place of residence may have no preference about where their care and treatment is given.

3.3.4 One patient who spoke to the investigation was sent to an OAP more than 300 km away. They told the investigation: “I didn’t have my family nearby and I rely on them to keep me well. I was sent to the south of England from the north because there were no beds.” The patient went on to describe how their family was not able to visit during their 4-week stay and they felt that being placed out of area had “prolonged their stay” in hospital once they had been repatriated to their sending hospital. The patient told the investigation that they had not been given any say in the decision to be sent to an OAP. They said that they had gone to an emergency department, been “taken to the local hospital [136 suite – see 1.4.2] and then directly to an OAP”. Many patients who were in an OAP or had been in an OAP previously told similar stories. The investigation found that this was not an uncommon situation.

3.3.5 Another patient in an OAP 40 km from their home told the investigation that they were “glad to be here because my life at home is really chaotic and I’m scared that when I am let out [discharged or granted leave] I will end up with my old mates and start using [drugs] again. I think that is what caused me to become unwell in the first place”. They went on to say that not only were they glad to be in an OAP, they did not want to be discharged back to their original residence and wanted the local authority at the OAP to find them new accommodation to “prevent them from mixing with people that make me use [drugs]”. They told the investigation that they had had no say in being sent to an OAP, but they were “glad” that they had been. Staff told the investigation that “the sector hasn’t understood that not all OAP is bad, it can also be good as it can break a cycle, for example social poverty and housing”.

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’.

3.3.7 All the carers and families of adults with mental health problems that the investigation spoke with said that they felt frustrated, angry and tired when the people they care for were sent to an OAP. They said that they were not consulted on the OAP or involved in any decision making because their loved one was an adult. They said that they knew the patient the best and could help healthcare staff develop treatment plans and be involved in discharge planning to make the process safer for their loved one.

3.3.8 Families and carers of children also described that when they were told their child would be sent to an OAP, they were given no choice and no consideration was given to welfare visits, distance or family circumstances. Families said that they were the “guardians of their children” and felt helpless, especially as they had “no say” in the OAP decision. They felt that their children were so vulnerable at the time that they were unwell and that was the “exact time when they needed mum and dad”, so the decision to send them away was difficult to understand and made them “very angry and sad and helpless”.

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’.

3.3.10 The guidance says that patient choice is important even when a patient is in crisis or acutely unwell, as ‘people are experts in their own lives and have valuable contributions to make’. However, the investigation found that including patient choice and needs was variable and in many cases patients were not included because of the pressures within the healthcare system.

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.

3.3.12 The Mental Health Act 1983: Code of Practice (Department of Health, 2015) states:

‘Wherever possible, patients should be engaged in the processes of reaching decisions which affect their care and treatment under the Act. Consultation with patients involves helping them to understand the information relevant to decisions, their own role and the roles of others who are involved in taking decisions. Ideally decisions should be agreed with the patient. Where a decision is made that is contrary to the patient’s wishes, that decision and the authority for it should be explained to the patient using a form of communication that the patient understands. Carers and advocates [see 1.4.4] should be involved where the patient wishes or if the patient lacks capacity to understand.’

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.

“Throughout the period of time the person is treated out of area the treating hospital should document the patient’s wishes and preferences but, by that point, the decision to place out of area has already been made. The patient’s wishes should be recorded and considered in any decision-making regarding transferring them to a more local hospital to their community/family. The provider treating the person cannot unilaterally decide to transfer the patient to a closer hospital to their home area – the patient must be accepted for transfer by a closer hospital.”

3.3.17 The investigation found that there is no requirement under the Mental Health Act 1983 to record or document the wishes and preferences of patients, families and carers, specifically in relation to OAP. However, patients, families and carers told the investigation that their voice matters and that it should be recorded and documented so that sending hospitals have all the information available to them for decisions around OAP.

HSSIB makes the following safety recommendation

Decision making and oversight

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’.

3.4.2 The ‘Review into the operational effectiveness of the Care Quality Commission’ report (Department of Health and Social Care, 2024a) discusses operational performance; of particular of relevance to the investigation was the length of time since a mental health service was last inspected. The report states:

‘CQC estimates that the average age of current provider ratings ‘overall’ is 3.7 years (as of the beginning of June 2024) although this varies by provider type’

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.

3.4.3 Some trust had pre-agreements with independent providers in place. Others tried to send patients to one independent provider all the time so that a relationship could be built and maintained between staff groups. Others took every case on an individual basis and took the next nearest bed possible to minimise the distance the patient would have to travel.

3.4.4 Some NHS trusts said that they tried to visit patients on a monthly basis to maintain a link with them and plan discharge and check care plans, but this was not always possible due to operational pressures at their trusts.

3.4.5 The investigation observed that once a patient was sent to an OAP, it became easy for the system to “forget” them. Several staff members told the investigation there was a subconscious thought that the “patient is now in a place of safety [at an OAP]” and they could now manage the next “patient to come through the door” and continue treatment for patients already in their acute and PICU wards.

3.4.6 The Mental Health Act 1983: Code of Practice (Department of Health, 2015) states that ‘The location of the placement, and considerations relevant to that decision, should be monitored and reviewed regularly’. The investigation found variability in how patient oversight is maintained when patients are sent to an OAP. The investigation observed multidisciplinary meetings at NHS trusts and OAP providers. In an OAP provider, many staff attended virtually, and in many cases they did not contribute to the discussions. These were staff from the local authority and ICB. 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. Other NHS consultants from sending hospitals told the investigation that if a patient was in an OAP they had no involvement in their treatment plan. The consultant said that a member of the nursing team may attend weekly OAP multidisciplinary meetings, but did not always have all the information to hand to contribute to the treatment plan and discharge or repatriation discussions.

3.4.7 The investigation found that although the NHS sending hospital had sent a patient to an OAP, it did not maintain responsibility or clinical oversight of the patient. This could prevent patients being actively managed, for example by looking for early discharge or repatriation opportunities and shortening length of the OAP and stay in hospital.

3.4.8 One NHS trust told the investigation that it had tried to ensure safety oversight of its patients in an OAP by employing three senior mental health nurses. They were responsible for monitoring patients’ wellbeing and treatment while they were in an OAP. The nurses told the investigation that when they first started in the role they would be able to visit patients. During the visits they spoke to patients and checked that they were getting the treatment that they needed in the least restrictive way possible, that their wellbeing needs were being met and that there were plans in place to repatriate or discharge them from the OAP. They said that they would be involved in those plans. They went on to say that as operational pressures mounted, for example because of staff shortages and illness, needing to do clinical work to maintain their skills, and the number of OAPs and distances they had to travel, they were less able to visit OAP patients. Some OAP patients did not receive a visit during their whole time in an OAP, which in some cases could be several months. Staff said that the intention of the role was good in principle, but was very difficult to carry out due to operational pressures. A previous HSSIB report identified similar safety concerns (Health Services Safety Investigations Body, 2024).

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.

3.4.10 The investigation heard from OAP providers that were responsible for the welfare and treatment of OAP patients in their care. They said that once an OAP patient had been “placed with them the NHS clinical input and welfare checks were minimal”.

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. People without a social support network may have to rely on advocacy services to speak for them after they are admitted as an inpatient. Advocates are trained in objectively representing the views of people who otherwise cannot speak for themselves. Many patients who are placed outside their local area are uncomfortable, feel vulnerable and need someone to speak on their behalf.

3.4.13 Advocacy is where a professional helps a patient represent their view in an objective way (NHS, 2022). These professionals are referred to as independent mental health advocates (IMHAs) and provide advocacy for any patient detained under the Mental Health Act 1983. Independent Mental Capacity Advocates can provide advocacy for any patient who lacks capacity to make decisions. Informal patients who have capacity to make decisions have no statutory access to advocacy.

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.

3.4.15 Staff and patients also told the investigation that the use of advocacy services was variable across the country. Patients who are on a learning disability and autism mental health pathway are overseen by the ICB (normally assigned a social worker from the ICB) to ensure that their needs are met (NHS England 2023b). Many patients said that they did not have an advocate assigned to them while they were in an OAP, and could not remember being offered one. Several staff told the investigation that when patient is admitted, their focus is on stabilising and starting a treatment plan. They said it could be an extremely busy time, and sometimes it was not a priority to have a discussion about advocacy.

3.4.16 The investigation observed that sometimes patients were unwell and not able to communicate their needs and wants to healthcare professionals, particularly when attending planning meetings. The investigation heard from staff and patients that sometimes the patient voice was the quietest in the room and that patients said what was needed to be discharged. The investigation observed that when there was no advocate assigned to a patient, it could be difficult to know who was speaking for the patient and their interests.

3.4.17 While there may be a plan to try to bring patients back to the sending hospital at the end of their OAP treatment, the investigation found no evidence of support being provided by the sending hospital, or through advocates, to support this aim.

3.4.18 The investigation observed advocacy being provided in a independent provider where an unwell patient was unable to articulate their views in a very public and intimidating forum (the weekly multidisciplinary team meeting). The investigation found that advocacy services were vital for that patient to be able to put forward their views for consideration in decision making about their care.

HSSIB makes the following safety observation

Beds and resources

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.

3.5.1 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.

3.5.2 The main focus of this section is the flow through acute mental health wards. However, other significant parts of the system, such as drug and alcohol misuse organisations and community mental health teams, are also explored because they have a significant impact on patient flow and demand for services. The admission process, along with other parts of the system, is not explored in this report.

3.5.3 Figure 5 is a simplified representation of flow through the mental health system. The investigation developed this by speaking to health and social care staff throughout the course of the investigation. The investigation recognises that in the real word this flow is not linear and patients may enter or leave the flow at various points, and that many of these individual parts of the diagram rely on each other and have significant interaction to ensure the patient gets the care they need. For example, community mental health teams, home treatment teams, and acute services interact regularly. The investigation found that the system is dynamic and to be efficient all parts have to work together. Any one of the component parts can cause blockages or delays in the system. Inefficiencies, under-resourcing or scoping of work in the community, blockages and delays can cause further admissions by not keeping people well in the community. This can be due to gaps in services to manage patients with complex needs, such as those with neurodevelopmental conditions, drug and alcohol misuse or therapies for anxiety and depression. The investigation heard from many community teams that there are not enough higher level trauma focused therapies. The investigation explored some of the significant interactions that impact patient flow (and in the next section, discharge) that can lead to the use of OAPs.

Figure 5 Simplified mental health patient flow diagram

3.5.4 Staff told the investigation that mental health care was like a “revolving door”. In many cases this meant that patients were discharged from acute care only to be readmitted within a few months. Once a patient entered the mental health system, they continued to rely on it for the rest of their life. Staff in one mental health trust that the investigation visited said that there were 10 patients in its local emergency department (ED) who needed acute beds, one of whom had been in the ED for 72 hours. It also had more than 10 patients in the community awaiting an acute bed, leaving community services to treat and manage “very unwell and high-risk patients”. The mental health trust said that it did everything that it could to keep local people in its local acute beds, and had an unwritten policy that patients who were not from the local area would be first to be sent to an OAP. However, due to the number of patients who needed an acute bed, it was inevitable that local patients would also be sent to an OAP. Staff told the investigation that the pressure on them to find a bed meant that patient choice could not always be considered.

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 co-ordinate 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.

An example of actions to improve patient flow and reduce OAPs

3.5.7 One NHS trust told the investigation that it worked on a principle of continuously monitoring patients across the whole mental health pathway and different services in order to improve flow. This trust had responsibility for community teams, home treatment teams and acute care. The trust’s senior leadership told the investigation that the trust did not regularly need to use OAPs as it had a process in place to manage flow across the whole mental health pathway. This process relied on ‘continuous triage’ where the crisis and home treatment team was key in assessing patients in the community but also identifying which inpatients in acute care could be managed in the community. This allowed patients for whom it was suitable to be “early discharged” and continue treatment in the community, enabling beds to be made available for the most unwell patients.

3.5.8 The trust’s senior leadership said that adopting this process took leadership commitment, joint bed ownership and management by clinicians and admin staff to ensure that continuous triage happened. Senior leaders were involved daily in understanding bed occupancy and patient safety and risks in the community. The senior leadership did recognise that by following this process, the home treatment teams might be holding increased risk in the community, but said that this was done in a managed way, with all patients being assessed by the medical and nursing teams for their suitability to be treated at home.

3.5.9 NHS England told the investigation that there was a strong national commitment to have crisis resolution and home treatment teams (CRHTTs) reach into acute care settings, to support early discharge into community-based care. It said that there was significant variation in the resourcing and organisation of these teams across the country, which meant the service they delivered was also variable. NHS England said that where CRHTTs participated in networks, such as those established by the Royal College of Psychiatrists (2022), they were more likely to have an in-reach to acute care capability. It said that “early intervention [in the community or in crisis] reduces [reliance on] out of area placements”. It went on to say that where there are CRHTTs that carry out in-reach into acute care, so that “low-risk patients can be discharged early into their care”, it has been shown to reduce reliance on 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.

Guidance: This can be achieved by operational policies, ward rounds, joint acute care reviews, supported leave arrangements, sharing the same base location, shared consultant responsibility or shared acute care workers.’

3.5.11 Another NHS trust said that it had LA mental health social workers embedded in the trust. The lead social worker told the investigation that the LA had transferred funding from the LA to the trust to allow this to happen. NHS staff and social workers said there was significant benefit from this arrangement and it had brought about efficiencies in flow and discharge, and broken down barriers between health and care staff. Staff did recognise that there were still some challenges with this working arrangement. While the social workers now worked for the NHS trust, the funding for social support and social housing still had to be applied for through the LA. This meant that the same levels of bureaucracy existed in this system as across many other areas of the country.

3.5.12 In conclusion, the investigation found that patient flow through the entire mental health pathway had an impact on the use of OAPs. Flow is a complex concept and has many factors, but in simple terms, efficient patient flow means fewer OAPs.

HSSIB makes the following safety observation

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.

3.6.2 Several NHS trusts told the investigation that “approximately 40%” of all of their acute patients were awaiting discharge, mainly due to funding for social care packages or social housing needs. They said that if this number was “reduced to 0%” they would not need to use OAPs.

3.6.3 The investigation spoke to some patients who wanted to stay as inpatients as they “feel safe and have found a home”. Discharging someone who was homeless could prove challenging, because they did not have an address to discharge them to. There were further challenges associated with putting social care packages in place and with finding appropriate housing. One trust told the investigation that they were seeing an increasing number of homeless people being admitted, and that they had three homeless patients ready and awaiting discharge who did not want to be discharged, with social care services unable to find them appropriate accommodation. Two of these people had been on the acute ward for 8 months and had been awaiting discharge for 3 months.

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”.

3.6.5 Several staff in NHS trusts and ICBs told the investigation that if there was better patient flow and discharge, it would enable them to focus more on early community intervention. They could also reduce the reliance on OAPs, which would mean that they would be able to avoid inappropriate OAPs and offer them to those who had a clinical need or preference for an OAP. Many staff said that they would prefer to offer OAPs at a neighbouring NHS trust rather than rely on independent providers. However, this would only be possible if there was capacity in neighbouring NHS acute hospitals, but currently the whole NHS system was at capacity. As an example of how little capacity there is in the system, the investigation heard of many cases of patients waiting in EDs for extended periods who needed acute care; in some cases patients were waiting for days. A social worker told the investigation that when they are notified that a person needs an assessment under the Mental Health Act, they could not “section” them if there was no bed for them to be admitted to. This means that patients can stay for long periods in the community or in a setting such as an ED waiting for Mental Health Act assessment and acute care.

Policy

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:

• principle 1: individuals should be regarded as partners in their own care throughout the discharge process and their choice and autonomy should be respected
• principle 2: chosen carers should be involved in the discharge process as early as possible
• principle 3: discharge planning should start on admission or before, and should take place throughout the time the person is in hospital
• 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
• 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
• principle 7: local areas should build an infrastructure that supports safe and timely discharge, ensuring the right individualised support can be provided post-discharge
• 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.

System variation

3.6.9 One NHS trust told the investigation about complexities in the system. The trust covered a region with multiple LAs and ICBs. This meant that it had challenges in knowing who to talk to about which patient. Furthermore, some LAs were more amenable than others to putting care packages in place. This created tensions between LAs and many LAs stopped attending discharge planning meetings, which made the discharge process very difficult. This problem was identified when the trust recognised that a patient would be in a more therapeutic environment if they were discharged to a new LA region, rather than to the LA in which they had previously lived. Another example given was a situation where no one LA would accept responsibility for a patient, thus delaying their discharge and creating a backlog. The trust said that there was confusion about who was accountable for patients when they no longer needed acute care, and that this created delays in discharge, meaning there was not patient flow. This in turn resulted in the need to use OAPs to keep patients safe. These situations were replicated in OAPs visited by the investigation and similar discharge accountability challenges were seen.

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”.

3.6.11 Another NHS trust said that it was in a fortunate position because it only worked with one ICB and one LA. This meant that it had been able to keep the social workers within the trust. The trust said that this was a great benefit to the trust and social workers, and to patients. However, while working relationships were good there was still a challenge relating to financial arrangements. In relation to discharge, housing and social care packages, one social worker told the investigation that funding still had to go through the LA processes, adding a layer of “bureaucracy” to something which could be resolved quickly if the NHS trust had the ability to control that money.

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’.

3.6.13 In 2015, the Better Care Fund was launched as a collaboration between the Department of Health and Social Care, NHS England, Department for Levelling Up, Housing and Communities, and the Local Government Association (NHS England, 2015). Its purpose is to ‘deliver the integration of health and social care in a way that supports person-centred care, sustainability and better outcomes for people and carers’. Areas that could be supported are:

• ‘supporting the implementation of discharge to assess and tackling inconsistent application, performance issues and immediate pressures in delayed discharges
• reducing pressure on urgent and emergency care and acute services.
• improving capability and capacity to undertake effective capacity and demand planning and modelling for intermediate care.
• accelerating implementation of integration and BCF ambitions and programmes
• reshaping pathways and community capacity to meet the changing demand from Home First and/or NHS Long Term Plan aims
• strengthening system leadership and collaborative culture, including developing integrated care systems and place-based partnerships
• developing workforce capacity, skills and a collaborative, multi-disciplinary culture across health and care jointly
• implementing system-wide recovery plans.’

3.6.14 The ‘Discharge from mental health inpatient settings’ guidance (Department of Health and Social Care, 2024b) states that partners in local areas should consider all possible funding arrangements, including:

‘funding arrangements in which funding is pooled across health and social care via agreement under section 75 of the NHS Act 2006. For example, funding which is part of the Better Care Fund’

The investigation was told by NHS trusts and ICBs that pooled funding could only work in simple aligned local structures [see 3.6.11]. When the system is complex, such as a single NHS trust having to deal with multiple ICBs and LAs, this practice of pooled funding resources cannot work.

3.6.15 The Mental Health Act code of practice (Department of Health, 2015) says that placing people as close to home as possible ‘will help to facilitate effective discharge and after-care planning’. The investigation heard from NHS trusts, ICBs and NHS England that patients in OAPs who need social care support or social housing are more difficult to discharge than patients with similar needs in an NHS trust. This was due to the challenges of being outside their normal LA area of responsibility and the potential for communication challenges between healthcare and LA staff who were not used to working together. However, they recognised that discharging patients from NHS acute care could also be challenging due to these factors.

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 un-needed extended stays in hospital”.

3.6.20 NHS England told the investigation:

“… the practice of using bed and breakfast accommodation to support people who no longer need to be in hospital to leave hospital is commonplace. Providers often have to balance the need to improve flow through their hospitals with managing safeguarding risks which can occur when multiple vulnerable people are placed into one bed and breakfast.”

NHS England said that the situation had to be managed carefully from a safeguarding perspective because while people who are discharged are more well than when they were admitted, they could still be vulnerable. The investigation heard from NHS staff about an incident where several patients were discharged to the same bed and breakfast which had created an opportunity for drug dealers and others involved in organised crime to prey on them. HSSIB has identified safeguarding risks relating to discharge in the other ongoing mental health inpatient setting investigations and this topic will be explored in detail in these.

3.6.21 NHS England said that the use of this approach provided a “step-down bed” which only works if there is the ability to find long-term solutions for patients in social housing.

3.6.22 The investigation spoke to one NHS trust that had adopted this model of taking on some of the social care system’s responsibility; it heard from NHS England that other trusts were also following this approach. However, the investigation identified that most NHS trusts did not operate to the this model. The investigation found that if NHS trusts carried out some of the functions of social care relating to social housing in order to support discharge, then lengths of stay in hospital after a patient had been assessed as ready for discharge were reduced, which in turn reduced harm and use of OAPs. The investigation also found that discharging patients to locally funded accommodation can have other unintended consequences, so risk decisions need to consider what is appropriate for the patient and the need to resolve patient flow.

Integration of services

3.6.23 Staff and patients said that patients who were discharged and returned to the same social circumstances that contributed to them becoming or being unwell, needed ongoing social support to prevent readmission. In the past, mental health social workers worked for many NHS trusts under what was termed locally as a ‘Section 75’ agreement under the NHS Act 2006. This was where social workers were commissioned and worked directly for NHS trusts. They said that this arrangement gave them greater visibility of patients in hospital, as well as those in the community and those under the care of social services.

3.6.24 Many NHS and social work staff told the investigation that this arrangement was of great benefit to the NHS, LAs and patients. It had improved efficiency and collaborative working, and there was greater understanding of cross-system pressures. Staff said they were able to manage challenges better due to “closer ties with healthcare”. Section 75 arrangements were withdrawn by many LAs several years ago. Staff told the investigation that this was due to operational pressures in other areas of social work. Social workers told the investigation that an unintended consequence of revoking the Section 75 agreements was that many social workers now did not have experience in mental health and may be assigned to a support a mental health patient without this experience. The Section 75 agreements are a key component of the Better Care Fund (discussed in 3.6.13).

HSSIB makes the following safety observation

3.6.25 NHS England told the investigation that while there was a statutory obligation under the Health and Care Act 2022 for ICBs and LAs to work together, doing so presented many challenges. Some LAs and ICBs were working closely together but NHS England recognised that this was “the exception rather than the rule”. Where there was good integration it was built on people talking, building relationships and having a common understanding of each other’s challenges.

3.6.26 NHS England said that these relationships can be fragile, and when priorities changed or financial pressures mounted, the relationships could break down and the system faltered. It said that just telling people that they have to work better together was not sufficient. The challenges were more “fundamental than this; they are politics, financial, societal, regulatory and statutory”. NHS England told the investigation that until there was “true integration of health and social care” the existing challenges between health and social care will continue.

3.6.27 NHS England stated that it was working with ICBs to “share best practice” on how better integration within ICSs, including LAs, could be achieved. It said that this was done on an ICB by ICB basis but that it did try to share learning across all ICBs. It said the integration between ICBs and LAs was still a significant challenge across the country due to variation of working, and the regional make-up of ICBs and LAs. Some ICBs were interacting with several LAs, each of which may have different ways of working and different priorities.

3.6.28 ICSs were set up in 2022 to integrate health and social care, with the aim of creating a seamless system for the provision of patient/people-focused care. However, the investigation found a difference between what the policy setters believe is happening and what is happening in practice. The Department of Health and Social Care and NHS England believed that ICBs/ICSs, while in their infancy, were working toward closer integration. However, many NHS trusts, ICBs and LAs told the investigation that in reality the gaps between the ICB and LA social care were “not growing closer but widening”. 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.

3.6.29 The ‘Close to home’ report (National Development Team for Inclusion, 2020) stated that:

‘Bringing out of area admissions to an end is extremely challenging and touches on all parts of the health and care system. It requires organisations to come together and find shared solutions. It cannot be solved by the NHS on its own, and local councils [local authorities] have a pivotal role in both social care and housing support.’

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. The variability was compounded by differences in legislation and guidance, and the lack of a national approach. NHS England told the investigation that there “had been a decision to not prescribe a national operating model for ICSs”. Staff said that the variation had created “rifts” between health and social care because of the “lack of direction”.

3.6.31 LAs are responsible to local government and the local population they serve, while NHS trusts and ICBs are accountable to NHS England through the NHS England regional teams. NHS England staff told the investigation that this created challenges relating to the timeframes within which the NHS and LAs work, which were also driven in part by the financial, political and regulatory structures they had in place. The investigation found that if there is an imbalance in organisations’ rules, governance and legal frameworks, it creates friction in the system which prevents integration, discharge and flow and ultimately impacts on patient safety.

3.6.32 The Department of Health and Social Care told the investigation that in recent ‘deep dives’ into healthcare systems it had found similar issues with LA and ICB integration, creating discharge and flow challenges. It had found that the imbalance of rules and regulations and governance was a significant factor in the challenge to integration.

3.6.33 NHS England also told the investigation that there were integration challenges due to “fundamental” problems with how LAs were governed, their priorities and those of the NHS. NHS England said that ICBs and LAs operated on an “uneven playing field as far as funding, regulation and statutory requirements”, which meant they found it difficult to integrate and provide seamless care across the health and social care system. They said that until both health and social care were operating to the same rules, managing patient safety would always be a challenge. The investigation found that current ICB and LA integration and working was variable and was not addressing patient safety concerns.

3.6.34 A previous HSIB investigation focusing on the urgent and emergency care pathway (Healthcare Safety Investigation Branch, 2023) found that an ‘air gap’ existed between health and social care which was having an impact on patient safety. It made safety recommendations to the Department of Health and Social Care relating to addressing the ‘air gap’ and around modelling flow in the urgent and emergency care pathway. Although its focus is on OAPs rather than emergency care, this investigation has identified similar health and social care integration challenges.

3.6.35 The investigation found that efficient and seamless ICB and LA interactions are vital to improving flow and discharge through the health and care system, therefore reducing OAPs and harm caused to patients, families and carers. However, because the health and social care systems operate to different, and sometimes competing, rules, statute, priorities, funding streams and governance, they cannot be truly integrated.

HSSIB makes the following safety recommendation

4.1.1 Community mental health teams (CMHTs) play a significant role in keeping people well in the community and trying to prevent admissions to acute mental health wards. NHS England told the investigation that there was a policy shift towards caring for people in the community and in the least restrictive environment (NHS England, 2019). All CMHT staff told the investigation that they were doing this by “holding greater and greater risk due to the acuity of patients” – that is, the patients they were treating had increasingly complex needs and were more unwell.

4.1.2 While the investigation did not look at community mental health provision specifically, it met with many community services during the course of the investigation. Staff in community mental services told the investigation that there was a will to keep people at home or in their place of residence as long as possible and to treat them there. They said that this was the most therapeutic environment and “much better” than being on an acute mental health ward and “infinitely better” than being placed in an OAP. They also said that if they could manage and treat more people in the community it would reduce the “demand on acute beds” and therefore “reduce the need for OAP”.

4.1.3 CMHT staff said that that they were able to provide lower-level talking therapies (such as cognitive behaviour therapy) to manage depression and anxiety. However, they told the investigation that they were unable to offer more complex therapies to help people with more serious mental health issues. This meant that they were unable to treat patients with more serious mental health concerns without transferring the patient to a home treatment/crisis team and then admitting them to an acute ward.

4.1.4 Many CMHT staff told the investigation that the community provision was “not enough” to deal with the demand and that staff were “burnt out”, with staff absence related to wellbeing concerns creating more pressure on remaining staff. They said that this had a direct impact on “patients deteriorating in the community” and therefore needing to be admitted to acute services.

4.1.5 The investigation found that if community mental health services had better resources and a wider range of more complex treatments they could prevent more admissions, thus removing pressure on acute beds and ultimately keeping people in the community and reducing OAPs.

HSSIB makes the following safety observation

The investigation’s findings were drawn from analysis of available intelligence (serious incident investigation reports, coroners' prevention of future deaths reports, research and policy literature) and through activities undertaken by HSSIB (observational visits, patient and staff interviews, wider stakeholder interviews and focus groups).

Stakeholder engagement

This is one of a series of HSSIB investigations into patient safety in mental health inpatient settings. This meant it was able to draw on evidence from across the four separate investigations in the series. Specific stakeholders engaged with primarily for this investigation are shown in table A and listed below.

Table A Patients and families, providers and regional stakeholders engaged with primarily for this investigation

The findings presented in this report were identified following triangulation of various evidence sources and following consultation with stakeholders involved in the investigation. The investigation approach was informed by the use of a blend of BOWTIE (Ministry of Defence, 2018) and the Australian Transport Safety Bureau models (n.d.) to help explore the complexities of OAP, and risk management frameworks to help understand risks across local, regional and national boundaries.