Reducing out-of-area placements : Avon and Wiltshire Partnership Trust

Overview

Avon and Wiltshire Partnership Trust reduced the number of out-of-area placements for patients receiving mental health services, to ensure that all patients across its large footprint could receive care close to home.

Key benefits and outcomes

• Reduction in out-of-area placements from a peak of 68 in 2020 to an average of 12 by the end of 2023. 
• No patients in out-of-area placements in December 2023 outside the trust’s geographical boundary.
• Savings of £7.12 million over three years.

What the organisation faced

Avon and Wiltshire Partnership Trust delivers a range of mental health services, including inpatient services for adults and secure services. These provide support and treatment and aim to help patients become well enough to return to living in their local community. 

The trust covers two ICSs across 1,100 square miles, serving a population of around 1.8 million across Bath and North East Somerset (BaNES), Swindon and Wiltshire, Bristol, North Somerset, and South Gloucestershire. 

This large footprint poses a challenge as it contains both urban and rural geographies, and it means that services are spread out. The location of the trust’s own services, particularly those for inpatient care, mean that patients may be placed far away from home. 

However, in some cases, patients were being placed outside of the trust’s footprint, including some hundreds of miles away. By being placed in an unfamiliar area, this added to the distress that patients were already facing and made it more difficult for their loved ones to visit. 

As well as being more difficult for patients and their families, data showed that patients placed outside of the trust’s area also had longer-than-average lengths of stay, indicating poorer outcomes, with discharge planning and continuity of care also being more difficult. 

Finally, even for patients placed within the trust’s area, some of these were with different providers, including those from the independent sector, which in this particular case made delivering care less efficient.

What the organisation did

The trust wanted to reduce the number of out-of-area placements and sustain that reduction.

In early 2020, an initial piece of diagnostic work was carried out to better understand the flow of patients. They found that frameworks and policy guidance that were in place to improve patient flow needed additional focus in order for them to be implemented routinely.

The trust held a rapid improvement phase to see what difference could be made, covering 44 wards  including 11 acute wards.

Some key actions and areas of focus included: 

1. To improve patient flow through the system, the trust began to focus more on the care pathway programme and re-promoted a red-to-green system. This involved clinical teams going back to the purpose of why each patient had been admitted, considering whether that purpose has been met or if they need further treatment, deciding on an estimated date for discharge, and then following these up with actions for the team to complete.
2. Section 136, processes and policies were reviewed, as well as building on the trust’s relationship with the police to understand how to improve the way that patients are managed who come in through this pathway. 
3. The trust used the GIRFT (Getting It Right First Time) principle to guide improvement work, referring to the 2021 GIRFT national report and its 17 recommendations for services. 
4. To support patients who were clinically ready for discharge, the trust worked more closely with partners including local authorities to quickly check care packages and ensure that plans to relocate patients to the community were appropriate for their needs. This improved the success of community care pathways and made the process of discharge safer and more effective.

A strong focus in reducing admissions was vital, and that involved working with the understanding that community treatment was the preferred option, as well as being clear about always defining the reason for admission and the intended outcomes.

Resolving out-of-area placements meant liaising with regional partners and the trust met with neighbouring trusts and networks to share knowledge and learning, including Devon NHS Partnership Trust, Solent NHS Trust and the South West Strategic Clinical Network.

Results and benefits

There has been a significant reduction in out-of-area placements from a peak of 68 patients in 2020, and in December 2023 the trust had no patient in an out-of-area placement outside of their geographical boundary.

James Eldred, clinical director for right care, said at the time: “This was a proud moment for the trust. Everyone I worked with understood that admitting patients to beds around the country was something that needed to change, but actually delivering that change has been a massive challenge and a very long process.  We take confidence from knowing that none of our patients will be admitted to wards far away from their homes. It proves that we can make a huge difference to peoples’ lives even when resources are tight, and the challenge is great.”

The trust is now aiming to eliminate the use of non-trust beds. 

Challenges and takeaway tips

• Consistency of messaging from leadership was important, as was the power of the narrative, which helped to develop a belief in the work being done. This was supported by clinical leadership, which was an important part of getting buy in from other clinicians. In particular, focusing on improved patient outcomes and experience, rather than money saved and raw numbers of out-of-area placements, was vital in getting clinicians onboard. 
• It was also important to ensure that trusting relationships were maintained between community and inpatient teams. The team found that both needed to become more comfortable transferring patients to one another, with this being facilitated by more effective sharing of information. Through conversations between inpatient and community services, they were better able to arrive at an optimum use of a hospital beds.
• Overall, the trust needed to take a quality improvement approach, looking at and measuring the opportunity cost of improving the system, including getting patients to a place of safety or a hospital bed, including with those referred through A&E. There was a continual reference to the best use of clinical/professional and managerial time to allow staff to focus on the placement of patients further upstream.
• It is important to remember that according to national guidance, there are a limited number of cases where an out-of-area placement may be appropriate, such as for safeguarding reasons or when a patient does not live in a particular area but opts to receive care there due to the presence of family and other networks. The focus is therefore only on reducing out-of-area placements caused by a lack of availability within local services.