Harmful out-of-area mental health placements on the rise

The report found that patients sent to a mental health inpatient facility far from home experienced distress and anxiety and were at risk of further psychological and physical harms including death by suicide.

“We desperately need new investment to grow the specialist nursing workforce and increase the number of mental health beds”

Ben Thomas

The report also found that the number of inappropriate out-of-area mental health placements went up in 2023, despite government commitments to eliminate them by the end of 2021.

The report from the HSSIB, published yesterday, gave the findings of the second of four investigations into NHS and independent inpatient mental health wards in England.

This week’s report is based on the HSSIB’s investigation of the impact of out-of-area placements on the safety of mental health patients.

Out-of-area placements occur when a patient cannot be cared for in their local NHS mental health acute inpatient setting and has to be sent to another mental health provider for ongoing treatment and care.

These placements can often be a significant distance from the patient’s home and family and have previously been shown to have a harmful impact on patients.

The HSSIB investigation reaffirmed that patients sent to out-of-area placements and their families and carers experienced harm.

Most commonly this harm took the form of distress and anxiety, but it could also extend to further physical and psychological harms including death by suicide.

Out-of-area placements also increased patients’ lengths of stay in hospital, contributing to further harm to patients, found the report.

The investigation also found that patient, family and carers’ wishes and preferences about where a patient should be placed were not documented by health and care staff or routinely monitored during Care Quality Commission inspections.

This is despite a requirement in the Mental Health Act 1983 Code of Practice that patient, family and carers’ choice should be taken into consideration when making decisions about where a patient is placed.

The Act also says that every effort should be made to place a person as close to home as possible.

The HSSIB report recommended that the Department of Health and Social Care (DHSC) ensured that patient, family and carer voices are considered in decisions relating to placements by including documentation of those wishes within the Mental Health Bill, which is progressing through parliament and will update the Mental Health Act.

The HSSIB investigation also found that despite a government commitment to eliminating inappropriate out-of-area placements, there was a trend toward increasing use of them.

The DHSC released guidance in 2016 setting out a “national ambition” to eliminate inappropriate out-of-are placements in mental health services for adults in acute inpatient care by 2020 to 2021.

However, NHS England figures show that the monthly number of out-of-area placements rose from 700 in March 2023 to 900 in March 2024.

And of the 900 out-of-area placements made between 1 to 31 March 2024, NHS England told the HSSIB investigation that 805 were inappropriate, made solely because there was not a local bed available.

NHS England told the investigation that the Covid-19 pandemic had been a significant factor in not achieving the goal of eradicating inappropriate out-of-area placements.

NHS trusts reported to the investigation that they were “overwhelmed” by the number of people needing acute mental health care.

They told the investigation that if there were “no beds available, it was better for the patient to be sent to an out-of-area placement than remain unwell and unsafe in the community”.

Commenting on the HSSIB report, deputy chief executive of NHS Providers Saffron Cordery said: “Trusts send patients out of their local areas for care only when they have no other choice due to a lack of beds, capacity or staff. It’s always a last resort.”

She added: “Stretched NHS mental health services are under pressure like never before with record demand.”

She said that NHS Providers “shared the HSSIB’s concerns” about inappropriate out-of-area placements.

But she added that years of underinvestment in mental health services meant that trusts did not have enough resources and staff to prevent every inappropriate out-of-area placement.

“We need to see more investment to improve mental health provision so that people everywhere can access high-quality services, as close to home as possible, when they need them,” Ms Cordery said.

The HSSIB investigation concluded that it was “impossible” to look at the mental health inpatient system in isolation.

It said that other health and care services such as community mental health services, social care and local authority social housing provision also needed to be taken into account when considering the factors that led to inappropriate out-of-area mental health placements.

The HSSIB therefore recommended that the DHSC should take steps to improve integration and collaboration between health, social care and local authorities to improve accountability and reduce or prevent out-of-area placements.

Royal College of Nursing (RCN) professional lead for mental health Ben Thomas called on the government not to “overlook” mental health services while it endeavoured to reform the NHS.

He said:  “Some of the most vulnerable are being shunted around the country at a time when they need stability. This is a symptom of a mental health system which has neither the beds nor the workforce to deliver care closer to home.”

He added that it was an “unacceptable” way to treat people, disrupting treatment plans, slowing recovery and delaying discharge.

“As the government looks to reform the NHS, it must not overlook mental health services. We desperately need new investment to grow the specialist nursing workforce and increase the number of mental health beds,” Mr Thomas said.

“We must also see a boost to the number of crisis resolution and home treatment teams alongside other support in the community to give patients the care they deserve,” he said.