Out of NHS area placements – new report finds positive patient experience of care, concerns over discharge planning, and lack of oversight of costs

A new report published today by the Mental Welfare Commission examined placements of people from Scotland with mental ill health or learning disability outwith their NHS health board area.

The Commission focused on 59 of the 162 individuals from Scotland who are in this category, with the majority being cared for in private sector facilities in Scotland or, for a few, in England. 

The Commission heard from them directly wherever possible, and from their relatives, and learned about their experience of referral, about their care and treatment, and about any plans for their return to their home area.

The Commission also sought to assess the impact and cost of these placements.

Positive feedback on care from those receiving care and relatives

Most of the individuals and relatives praised the quality of care and treatment in the out of area placement. The majority of individuals felt their care was better than before the move, and that they were involved in that care. But being far from home had an impact on relatives and family relationships.

Long stays, lack of discharge planning

The average stay at the point of the report’s research was over eight years, with one person living in out of area care for 28 years. 

Discharge planning was a concern for both the current service providers and for the health boards who made the referrals. For the current providers, they identified that getting engagement from the funding health board could be challenging and slow; for the funding service, it was around their concerns relating to a lack of an appropriate local service, and the risk of relapse for the individual.

Funding – lack of oversight of costs

The Commission sought to estimate costs, but found a lack of accurate information. The Commission gives a very conservative estimate of over £13 million a year being spent by NHS Scotland services on out of area care and treatment for the 59 people who were included in the report. The Commission expects the figure to be higher in actual costing, and considerably higher for the total number of people living in out of NHS area placements. 

Claire Lamza, executive director (nursing) at the Mental Welfare Commission, said:

“When people with mental ill health or learning disability are placed outwith their NHS health board area for care and treatment, they are likely to have highly complex, specialist needs that have been assessed as not being able to be met by their local health services.

“This report examined in detail the care in place for 59 of the estimated 162 people who are living in out of NHS board areas, almost all of whom are in private sector facilities. We were reassured to hear positive feedback from individuals and relatives on the quality of care, but we also heard they were unsure of the plans that were being put in place for a return closer to home and about the impact on relatives of travelling to see their family member, and the toll that this took on their relationship.

“When we sought to clarify with health boards the costs and oversight of these placements we found gaps in information; we believe our funding estimates are likely to be considerably lower than the true costs. 

‘’I hope our report is useful for government and health boards, and for families and individuals who have spoken to us about their experience. Our recommendations include setting new standards, developing accurate data collection and creating a national oversight and scrutiny role. 

“We also ask Scottish Government to take a human rights and health economics based approach and consider whether a regional resource should be developed for those individuals who are considered at greatest risk of being out of area.”

The Commission made seven recommendations for change: 

1. Scottish Government formally review the categories identified for publishing data on those patients who are out with their local health board area. 
2. Scottish Government develop a data gathering process for out of area NHS board placements which is verified and accuracy can be assured. 
3. Scottish Government should commission the development of a set of standards from referral to transfer with involvement of those receiving the care and treatment, their carers/family and those most important to them (as appropriate) that outline the key steps required for an inclusive, supported approach to planning an out of area placement.
4. NHS Boards who are funding an out of area placement should jointly develop and incorporate a structured plan with the independent healthcare provider that includes rehabilitation and engagement back to the local area where the person will be returning to.
5. NHS Boards develop and apply a set of discharge planning standards informed by cross agency multi-professional groups and those with experience (carers and people with experience of services) which focus on recovery and return to local areas.
6. Scottish Government review the monitoring of the funding costs for out of area placements and sit this with a national organisation such as NHS National Service Scotland, through the National Services Division, for centralised oversight and scrutiny. 
7. Scottish Government consider a human rights and health economics-based approach as to whether regional units should be developed for those individuals who are considered at greatest risk of being out of area.