A recent report by the London School of Economics How mental illness loses out in the NHS highlighted an underinvestment in mental health care in the UK.
With tightening budgets all areas are feeling the squeeze. But other research suggests that mental health could receive a big boost, with very little financial outlay, if the cost of out-of-area treatment was examined.
In 2010 the Royal College of Psychiatrists reported that £300m a year is spent on out-of-area treatment, accounting for more than one in five undergoing treatment out of area, and being on average 66% more expensive. The NHS Confederation’s Mental Health Network suggested that commissioners should be looking at how many placements they were making out of area and why, as well as developing strategies to reduce this.
Out-of-area treatment reasons
Reasons given for the need for out-of-area treatment vary. Sometimes people need specialist care which cannot be provided in the immediate area. Or it may be felt that for reasons of patient confidentiality it is better to place the person out of area. When NHS Leeds and Leeds Partnership Trust conducted studies into the areas – from 2004 to 2008, and again from 2009-2010 they found lack of capacity to be the main reason.
For patients being treated out of area can mean being cut off from their friends and family, who may find the journey to visit them both lengthy and expensive. This can be detrimental to the person’s recovery.
As well as highlighting the scale of the problem, the Royal College of Psychiatrists has questioned why mental health is the one area where this tends to be an issue. Figures for out-of-area treatment for people with physical illnesses are nothing in comparison to what is seen in mental health.
One trust which has made a conscious effort to tackle the problem is Oxleas Foundation Trust in south east London. Through its work with PCTs and social care commissioners it has reduced the number of patients treated out of area in Bromley from 12 to three in four years, from 21 to three in Greenwich, and from 13 to six in Bexley.
‘Where this work started was that I had a perception that although we have joint commissioning there was a sense that local authority and health weren’t necessarily seeing the whole picture. They were only seeing their bit of it. And so, through talking to them we started to work together as a whole system,’ says Iain Dimond director of complex adult mental health and learning disability services.
One man was out of area in a specialist unit for people with mental health problems who have hearing impairments. Once staff at a local unit received extra training they were able to bring him back. But in many cases no extra training has been required.
‘It is really about trying to reaffirm with the staff that they have the skills to do this. It is not always an easy sell to staff and it is often a long process,’ says Mr Dimond. ‘Clinicians have to be on board with it. It is not a question of me as director or other managers telling clinical staff that they have to accept this person back. There is often a lot of dialogue and we have to weight up the risks of accepting someone back to our services.’
Not everyone has been brought back into area, but each case is reviewed regularly, meaning that this may change in the future.
It is this reviewing policy which is important says Simon Lawton-Smith, head of policy at the Mental Health Foundation.
‘I think the message for trusts is that they should all be reviewing their out-of-area treatment on a regular basis. We would expect all trusts to be very aware of the cost of out-of-area treatment and to know the reasons why they are out - to be actively reviewing the situation. And I think that doesn’t happen in every trust so I would like to see more trusts taking it seriously and maybe doing that every quarter. They should also take a review of what services they do have in house - rehab in particular. To ensure that the money they are spending is being spent in the best possible way.’
In Oxleas’ experience commissioners have been very amenable to discussions about change with good reason.
‘This has released savings for the CCG, so it has been a win for commissioning, a win for us and a win for the service user,’ says Mr Dimond. ‘Commissioners have been very receptive to this. As long as they can be assured that there are good quality gains for the individual they go along with the idea also of saving money.’