Blog - “Don’t hit the target but miss the point”

03 October 2018

All of the hard work and initiatives to improve the acute care pathway have contributed to a reduction in acute mental health out of area placements, shown on the NHS Collaboration platform but there is still more to do. In 2017/18 in England there were 8220 acute metal health out of area placements started, making up 214,945 bed days out of area. 75% of all bed days were in independent sector beds and these accounted for approximately 85% of the recorded costs. The placements in the independent sector tended to have longer lengths of stay (over 2.5 times more likely to stay over 31 days) and required people to travel further from their homes (over 13 times more likely to travel over 100km).The cost of all out of area mental health placements last year cost the NHS over £90 million which could be better spent on strengthening the local mental health provision. (NHS Digital, 2018).

The aspiration to eliminate acute out of area placements by 2021 has clear drivers to improve care, experience and increase efficiency. The complex factors contributing to the reasons for mental health acute out of area placements and the challenges and constraints facing the NHS and in particular mental health services impacts on the STP’s ability to achieve it, but the aspiration does address a key public issue.  As a by-product it leads to a proper review of the acute care pathway, which undoubtedly will drive other beneficial step changes. Whether it is deliverable within available resources without causing more harm than good, and so is a reasonable proxy, is a valuable question for each system to ask. In our experience, working alongside the National Team and visiting numerous STPs across the country we feel that as a proxy it is reasonable and worthwhile, but that attention is required to ensure the methods of achieving it are reasonable in relation to return on investment in both human and financial terms:

  1. It’s not a target for targets sake- Having the set specific target prioritises this agenda for STPs and offers opportunities and support to develop local plans and trajectories.  The target is focussed on a defined group of people at a defined identifiable point in the pathway (admission to acute care) and for which much data is collected already. In addition, statutory reporting on the numbers of bed days out of area each day to NHS England split by providers and commissioners, can inform trajectories and promote joint accountability, integrated working and identify wider system solutions. However, any targets can also promote perverse incentives or unintended consequences which carry significant risks. These risks could lead to insufficient investment in effective community care. Examples could include people being turned away from acute care who are in need of an inpatient bed, people being admitted to the wrong bed for their needs in area, people being moved into tertiary inpatient care from acute care to maintain flow. In the wider system they could include an increasing threshold for people being eligible for community mental health support to manage overall demand and capacity.  All may support the achievement of the target, but are not reasonable and will not improve population health or the experience of care. The greatest priority is patient safety and focussing on the aim that nobody loses a day in the community than essential for their care and treatment, but everybody needing an inpatient bed to be in the best bed for their needs that day.
  2. The best bed is not always the nearest- The target could imply that care and treatment in local wards will be better. This is arguable, although an excellent local unit will be better than an excellent out of area unit in relation to the significant human, social and financial costs of out of area placement, but local care does not necessarily equate to the safest and most effective care. For example, the aspiration that all people will be able to be treated locally presents challenges for STPs. To reduce reliance on inpatient care to maximise investment for community services, would likely require the closure of some inpatient beds which as a result could mean some people will be required to travel further to access care. To create multiple smaller local units so that everybody could receive acute care in their neighbourhoods will come at a significant financial cost, meaning less resource for the community and fewer people being able to access any service, and inpatient units that are more disparate, potentially impacting on patient safety and care. If local units are too small they won’t be cost effective and won’t be suitable for the broad range of needs in the community. Therefore, systems need to consider that whenever inpatient care is required, where can offer the best and safest care closest to home for that person’s needs.
  3. Wherever possible acute care should be delivered at home -Much of the discussion in relation to the elimination of out of area placements focuses on the ‘placement’ i.e. an acute bed, where they are, how many there are, and whether there is a need for more. An acute bed is just a tool in a process, and in itself it neither improves nor worsens care, experience or efficiency in isolation of wider factors. Every admission even to a very local hospital is a disruption to the person’s home life and social networks so is a major step to take. If a person needs care and treatment that can only be provided in hospital, they should receive the best care for their needs in the nearest suitable unit.  If they have to go out of area (for whatever reason), there needs to be a clear pathway for their care and real time information to inform their care plan. This includes that they should be able to be visited regularly by their care co-ordinator to support them in their discharge, and maintain regular contact with their families, friends and support networks. However, wherever possible the best acute care should be delivered at home recognising that generally people don’t want to lose a day in the community by being in hospital, and for people with severe mental illness, who are known to die 15-20 years earlier than the general population, (NHS England, 2014) every day is even more valuable.
  4. Be honest - there is support on offer- Principles of quality, patient safety, continuity and person centred care are discussed at the NHS England Support visits. These visits enable commissioners and providers to explore all of the complex issues and receive support to check the efforts being undertaken to achieve the aspiration are reasonable. The clinical advisors are able to act as a critical friend reviewing locally developed plans, maximising strengths and opportunities, strengthening clinical leadership and creating a network for sharing local successes and challenges. Human Factors are also discussed during the visits acknowledging that people whether accessing, delivering or commissioning care are all people, and that whilst the definition and accurate counting are important, this shouldn’t become a distraction from the key issue of improving efficiency and the effectiveness of pathways to deliver the best outcomes possible within available resources. To be person centred systems need to give people the confidence that they matter as individuals but also that the system is the best way of using delivering the best outcomes for them that can possibly be achieved with available resources. Examining variance enables learning and sharing and if extra resources do become available ensuring the system is well placed to make best use of them. In mental health services we haven’t always been good at writing up and sharing what works. The programme has accelerated learning and sharing across STPs and across the country as each area brings its own learning and innovations into the discussion. Being honest about the starting point and the challenges having to be overcome, enables more valuable help and support to get the trajectory to zero.
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