Meridian Productivity are delighted to be featured in a recent article in Public Finance magazine on providing care closer to home.
“The scale of reduction is truly transformational”
Bradford District Care NHS Foundation Trust succeeded in fully eliminating the use of 22 private placement beds over the course of just a 4-month period. This position has now sustained for over two years using a newly installed series of management controls. Listen to the team explain how they managed to completely eliminate their Out of Trust spend and return all service users to local treatment.
Public Finance Magazine – Article – Ann McGauran
Adults with mental health problems should no longer be placed inappropriately in acute care away from home by 2020-21, the government has said. Given this, do plans for place-based care in England focus enough on ensuring patients get treated close to where they live?
The 44 sustainability and transformation plans (STPs) were produced last autumn to meet local health and care needs. Each is a collaboration between health, social care and other bodies to improve health and wellbeing, put finances on a sustainable footing, and transform care quality. Placing people out of their area inappropriately in expensive hospitals, often in the independent sector because local inpatient mental health beds are full, runs against all the place-based principles behind STPs.
As well as the financial consequences, there can be negative effects on patients. Geoff Heyes, policy and campaigns manager at mental health charity Mind, says: “When people are sent far away from home and their support networks at such a critical time, it can have a profound impact on their mental health as well as their long-term recovery. We also know that the risk of suicide increases when people are sent to a hospital out of their local area.”
He adds: “Mental health has historically been underfunded and services are in need of significant investment if we are to end scandals such as people being sent hundreds of miles from home to get emergency care.”
While NHS England has promised to invest an additional £1bn in mental health care, Heyes says that “it is essential this funding reaches frontline services”.
The NHS Confederation’s Mental Health Network reported a fall in real terms in NHS mental health funding of 8% over the last parliament. Figures disclosed under the Freedom of Information Act for 37 of England’s 56 mental health trusts revealed that 4,447 patients were sent out of their area in 2014-15 – up 23% on the previous year. For the 29 providers that held data on costs, the total bill for this rose to £65.2m in 2014-15. A snapshot NHS Digital survey of all out-of-area care that started on or after 17 October 2016 and was active until the end of that month showed 191 inappropriate out-of-area placements had been made.
Chris Naylor is senior fellow in health policy at health think-tank the King’s Fund, which has reviewed all the STPs that were submitted by October. Examining a sample of 20 STPs for PF, he says “two thirds said something on out-of-area [placements]”. Mental health is receiving more attention in some STP areas than in others, he observes.
Some STPs are “addressing mental health as a standalone [matter], looking at how they can improve productivity in the mental health system by considering things like reducing out-of-area care, and some are looking at the rationalisation of inpatient sites,” she notes. “So there’s looking at mental health as a standalone service but, for some STPs, we are seeing mental health embedded in all their work streams and that’s what I think we need to aspire towards.”
Bradford District Care NHS Foundation Trust ran a successful four-month project in 2015 to eliminate out-of-area placements and increase productivity. It has avoided making such placements since.
Liz Romaniak, director of finance, contracting and facilities at the trust, tells PF that the project, run with consultants Meridian Productivity, was one of Bradford District Care’s interventions linked to the 2014 Mental Health Crisis Care Concordat; under this England-wide programme, organisations agreed how they would support and care for people having a mental health crisis. The Bradford project included services collaborating with commissioners to develop the First Response service for local people experiencing a mental health crisis. This is available 24 hours a day, seven days a week. The local clinical commissioning group provided £500,000 of one-off funding to enable the trust to recruit permanent staff to set the service up.
Romaniak says that, around the time of the concordat, a whole-system approach had been taken to crisis care, involving the trust, the local authority, CCGs, police and the voluntary sector. However, by the middle of 2014-15, the trust was projecting a likely overspend of £2.2m on out-of-area placements.
Consultancy company Mental Health Strategies looked at activity on inpatient wards and identified problems with patient flow. The trust addressed this first, Romaniak explains. “Flow can be about how effective we are within our system at getting people in and out, or it could actually also be because we have a gap within our care pathway.”
The trust brought in Meridian Productivity to look at patient flow. The company worked with trust staff to redesign processes. At the same time, the First Response service went live, “and there was a real coincidence of two great things that really helped”. The teams, says Romaniak, identified 10 “blockers to discharge – 10 key activities that needed to have been completed before someone could be discharged”. These included, for example, “simple practical things like what needed to happen at home, through to the medications [plan]. The most important thing that happened was on the first day of admission there would be a plan for discharge”.
This enabled community mental health and intensive home treatment teams to concentrate on their work while the First Response team acted as gatekeepers.
Around this time, a night-time crisis service called the Sanctuary was set up, supported by systems resilience funding from commissioners. In 2016, the trust worked with voluntary sector body the Cellar Trust to set up the Haven – a daytime adult mental health service that aims to prevent crises from escalating and provides an alternative to attending an accident and emergency unit. Naylor concludes that the focus some STPs are putting on whole-system working presents opportunities to integrate mental health with the rest of the system. However, he adds that, while some ideas have gained currency, “there’s still some work that needs to be done in terms of how you put that into practice and put it into operation”.
Ann McGauran is a public policy journalist