Out of Area Treatment

02 March 2018

The Panorama programme based at Winterbourne View Hospital 1 demonstrated the risks of people with complex health needs being placed out of area, out of sight, out of mind and away from their support networks including their local professional teams. Whereas it is recognised the abuse uncovered at Winterbourne View is not commonplace, the evidence suggests that despite out of area placements costing 65% more than local placements, they are socially dislocating for service users and are of variable quality. 2.

Acute mental health inpatient staff and staff on Assessment and Treatment Units work tirelessly to support someone in their recovery and return home at the earliest opportunity, however, there is a cohort of people whose problems don’t respond positively to standard interventions, don’t recover as quickly as hoped and don’t fit into local models of service provision. For those, who often are considered “too complex”, tertiary inpatient care/inpatient rehabilitation /“specialist” hospital treatment offers the best chance of recovery.  Dependent on what services are commissioned locally, this can require people be sent out of area for tertiary treatment.

This raises the question as to whether “Specialist” placements out of area offer the value required to mitigate the significant human, social and economic costs?

Without having a centralised Specialist Rehabilitation focus, offering review and intervention such as CWP’s Complex Recovery Assessment and Consultation (CRAC) Team, people are at risk of being sent out of area for “specialist” treatment, potentially to an inappropriate setting and getting stranded there.

The CRAC Teams works in 4 main ways to prevent this:

1CRAC gate-keeps all tertiary inpatient care in and out of area: CRAC has an extensive knowledge of what local services can offer, what care providers could develop on a bespoke basis and where will offer the best outcomes for as specific set of needs. CRAC can and does ensure that least restrictive options are always explored first and best use is made of available resource3. CRAC only supports someone being placed out of area when this is the only option that will support a person’s recovery and maximise their chances of living successfully in the community in the future.

2. Wherever possible keeping the people with the most complex needs closest: Being away from home, especially when it may not be your choice, can be difficult at any time, however at a time of crisis or ill health, this would be particularly stressful. It is well known that people with a mental health condition are vulnerable to relapse when stressed, so being away from family and friends for any extended period of time, not only contributes to stress but reduces the coping strategies that a support network may bring. This can hamper their recovery, especially when they have multiple co-morbidities and complexities resulting in a general resistance to treatment. Additionally, rehabilitation programmes are based on building skills and responsibilities outside of hospital and in the community a person wishes to be discharged to. Most often people want to return home. Valuable community interventions necessary for repatriation are extremely difficult to achieve if they are placed miles away. These include building links, developing skills and activities, and testing known risks and vulnerabilities to inform discharge planning. As a result this could potentially extend a person’s length of stay in hospital. CRAC work to try to minimise any unnecessary disruption to a person’s life and recognise that keeping people with the most complex needs closest often will optimise their recovery.

3. Having oversight of everyone out of area: Historically in CWP care co-ordination of adults in out of area hospitals was provided by individual professionals in Community Mental Health Teams, or Community Learning Disability Teams and the lack of central knowledge and clarity meant care co-ordinators did not have opportunity to share information about the best placements for particular needs or any low level concerns with colleagues. They were also unable to benefit from any efficiencies in seeing all people at a particular placement together and found balancing the occasional role of an out of area review with their local community role increasingly challenging. The CRAC Team with their specialist knowledge and skills in rehabilitation have a sole focus on all of those people out of area and repatriating them at the earliest opportunity. This is through regular person centred review, constructive challenge, partnership working with commissioners and care providers and having a broader of view of what is needed to be developed locally to inform strategic planning.

4. If a placement does not exist locally- develop it: A person with very complex needs may not fit a local support provider’s criteria. A period of inpatient rehabilitation may be very useful in supporting a person to function at their optimum, identifying their strengths, needs and aspirations and what support they will require to leave hospital. However, if the service they require does not exist, a person cannot wait in hospital, especially if this hospital is out of area, in the hope their requirements will change in the future. Often people with complex needs will have residual symptoms, ongoing health and social care needs. This does not necessarily mean they need ongoing hospital treatment if a less restrictive bespoke community option were available. The CRAC Team explicitly state what would be required for any person stranded in hospital to be discharged, clearly presenting this to commissioners, to stimulate market development. Often these options are cheaper, safer and very much better for the person who returns home and continues to work towards their aspirations. In practice, this is an ongoing challenge especially where commissioners perceive themselves as having very limited flexibility to put in bridging options and/ or re-invest monies currently spent out of area on developing and sustaining local solutions.

In summary, whereas there is a place for out of area specialist placements in the treatment of people with complex needs, there has to be careful consideration if the place is far away as to whether the benefits are worth the costs.

Related reading:

  1. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213215/final-report.pdf
  2. http://www.rcpsych.ac.uk/pdf/JCPMH%20Rehabilitation%20Services%20for%20People%20with%20Complex%20MH%20needs%20Nov16.pdf).
  3. http://www.rcpsych.ac.uk/pdf/Old_Problems_New_Solutions_CAAPC_Report_England.pdf
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