Out of area treatments for mental health patients have become increasingly common in recent years, but what are the costs to service users and services? Jeremy Pritlove investigates:

In recent years, an all-too-common feature of mental health services has been the sending of patients far from their own community to receive inpatient care. This process is known as ‘out of area treatments’, where local health trusts purchase care outside their own area for their patients.

Concern has been expressed nationally about the extent and effect of out of area treatments by the Royal College of Psychiatrists (2010) and the Healthcare Commission (2004), among others. The Royal College of Psychiatrists concluded that “hundreds of millions of pounds are being wasted each year on out of area treatments. Not only does this not make economic sense, but people may be taken away from their families and communities for no good reason”.

The origins of out of area treatments lie in the reduction of NHS inpatient psychiatric beds over recent years, and the resultant increased pressure to find enough beds locally for patients requiring treatment and care.

The Leeds studies

In Leeds, concern about the number and effects of out of area treatments in the mental health service led a local independent health monitoring group, Leeds Hospital Alert, to undertake two studies: information on out of area treatments over the period 2004–2010 was obtained from the provider trust, Leeds Partnerships NHS Foundation Trust, and from NHS Leeds, the commissioning trust.

The first study covered the period 2004–2008 and the second 2009–2010. The results of the first study were published by Leeds Hospital Alert in May 2009.

The Leeds studies provide a picture of what is happening with out of area treatments in one large urban community. It is a disturbing picture that raises many questions and gives rise to great concern about patient care, but also one in which there seems to be a real measure of improvement.

In the absence of national statistics on out of area treatments in mental health, local studies such as those undertaken in Leeds may well be the only opportunity to understand what is happening in this important area of care.

Numbers of Leeds patients sent out of area

Over the six years studied, the number of patients sent outside Leeds for inpatient psychiatric treatment increased by a factor of eight, from 23 in the first 12-month period to 196 in the last.

However, within this overall trend there has been a sharp change in the last year covered (2010). Up to 2009, there was a steady year-on-year growth in numbers, reaching a peak of 403 in 2009. However, 2010 saw a dramatic decline to 196.

This change followed the publication of Leeds Hospital Alert’s 2009 report and action taken by the provider, Leeds Partnerships Trust, to reduce the number of out of area treatment placements.

Leeds out of area treatments: the personal cost

What out of area treatments mean in practice for patients and their families and friends is illustrated by the distances involved in placements. The great majority of these were in Bradford or Harrogate, 10 and 15 miles respectively from Leeds, but still a significant journey for family and friends to make regularly. However, some patients were sent as far afield as Durham (80 miles), Northamptonshire (131 miles) and London (196 miles). Travelling to see patients out of area must be especially difficult for relatives and friends who use public transport, have young children with them, or are on low incomes.

This relates closely to a national study that showed that “significant numbers of people were placed at great distance (i.e. up to 300 miles) from home” (Ryan & Rayne, 2004).

Over the six years studied, the proportion of patients sent considerable distances – that is outside west or north Yorkshire – fell from 20% to 6%, which is clearly a great improvement. In 2009, 29% of these distant placements lasted five days or less, which indicates considerable dislocation for patients. However, this reduced to 6% in 2010.

By 2010, half of all patients subject to out of area treatment had placements lasting five days or less. At the other end of the spectrum, the proportion of patients placed for more than 21 days had almost doubled over the period, to 9%.

It is fairly obvious that patients ordinarily need close links with their families, carers and their local communities to aid their recovery. The Healthcare Commission (2004) considered that “local inpatient care should therefore be provided as close as possible to the home so that family and community links can be maintained.”

Placing a Leeds-based patient in Harrogate, Durham or London does not meet this requirement. The Leeds out of area treatment team works to overcome these difficulties by allocating a care co-ordinator who is responsible for supporting contact with family and other carers, and for patients’ contact with advocacy and other services. It is difficult to see, however, how this can truly overcome the problems arising from such a huge dislocation for patients and their carers.

Leeds out of area treatments: the financial cost

An investigation by the Royal College of Psychiatrists in 2010 showed that the national financial cost of out of area treatments in mental health was around £300 million, and that these placements were on average 66% more expensive than local treatments (RCPsych, 2010). In Leeds, between 2004 and 2007, the cost of out of area treatments was some £4.4 million, an average cost per year of £1.47 million. From 2009–2010, the cost was about £2.88 million, an average cost per year of £1.44 million.

These figures do not include the cost of transport to and from the placement. This cost would, of course, involve two round trips, one for admission and one for discharge, as well as trips for care co-ordinators working with patients. In the period 2004–2008, mileage involved simply in the admission and discharge of the number of patients concerned to the various destinations is estimated to have been 22,972 miles. The financial cost of this, in terms of ambulance or taxi transport and staff time, must have been considerable.

There is also the cost of the out of area treatment team to be added to this. These costs do not, of course, include mileage undertaken by family or friends visiting patients. The Leeds Partnerships Trust pays travel costs for carers and friends to visit patients placed out of area.

In 2010, 64% of placements cost up to £4,999 each, and at the other end of the spectrum, 13% cost more than £10,000 each. An important feature of the money spent by Leeds health commissioners on out of area treatments is that the majority of this expenditure went to private healthcare providers. From 2004 to 2009, more than two-thirds of placements were with private providers, but this fell to just over half in 2010.

Moreover, the longer a patient stayed out of area, the more likely it was that the provider was private. In 2010, 52% of those placed for five days or less were with the private sector, but 74% of those staying over 21 days. Most of these private sector placements were with one provider, Cygnet.

These figures raise questions about value for money and about a ‘creeping privatisation’ of mental health care. The Royal College of Psychiatrists (2010) stated that the “rapid and uncontrolled rise in independent sector provision of out of area treatments... does not match clinical need, and a large proportion of the money currently spent on such placements could be re-invested locally.”

Why out of area treatments?

Given the obvious anti-therapeutic effects of sending a patient miles away from their community, and the massive costs involved, it is reasonable to ask why this practice has become such a routine feature of the care system in Leeds, as well as elsewhere. Jeremy Pritlove was previously mental health development manager at Leeds social services department, and retired from that post in 2004. Before holding that post, he was a mental health social worker in Leeds. He is currently a member of Leeds Hospital Alert, a local independent health services monitoring group.
The great majority of out of area treatments over the recent period were simply due to the lack of inpatient beds in Leeds itself. For the years 2009–2010, the provider, Leeds Partnerships Trust, provided the reason for each out of area treatment placement, which showed that almost all placements were due to “lack of capacity”.

However, this reason for placements appears to have lessened slightly, from 96% of placements in 2009 to 83% in 2010. Those out of area placements that were not the result of lack of service capacity were due to several factors: clinical need – for example, a specialist service not available in Leeds; placement outside Leeds in order to protect their confidentiality; and a Leeds patient presenting as unwell in another part of the country.

That lack of capacity is the major reason for out of area treatments is an indictment of the previous policies of reducing local inpatient beds.

A significant feature of out of area treatments in mental health is that this practice does not seem to be reflected for other patient groups. Indeed, it may be that people with mental health problems are, in effect, subject to a discriminatory difference compared to other patients. As Helen Killaspy from the Royal College of Psychiatrists put it in a report in The Guardian (2010): “it is hard to find another example in the NHS where a patient has to leave their hometown and move to a facility miles away... merely to access a standard treatment environment.”

Out of area treatments: Leeds Partnerships Trust’s response

Leeds Partnerships Trust states that its aim is: “to ensure that all service users will receive high levels of appropriate care and treatment within services local to them”.

The trust has taken action to reduce the number of out of area treatments and there has been a large fall in the number of such placements from 2009 to 2010: 403 to 196. The trust has focused on several initiatives to further reduce the number of out of area admissions. These measures are:
· Use of the trust’s overnight suite (placement within the crisis team) to prevent out of area placements
· A review, with service user representatives, of admission and discharge processes, involving an improvement project for the psychiatric intensive care unit
· Working to identify options for joint initiatives between adult and older people’s services.

The trust also states that when an out of area placement does occur, wherever possible service users are placed with neighbouring facilities and returned to local services as soon as practicable. Contact is maintained during the admission period and support is provided to carers and families.

Out of area treatments: what next?

National studies show that the picture in Leeds is not unique and that out of area treatments are an important feature of mental health services across the country. A picture emerges of patients regularly criss-crossing England at huge personal cost to them and to their families, and at huge financial cost to the NHS and the taxpayer, with only private healthcare providers profiting. There would seem to be almost no therapeutic or financial benefits involved in this process, yet it has grown enormously and seems to have been accepted as a routine part of the service.

The personal cost of these placements to patients and their families is enormous (Mountain et al, 2009). When added to the financial cost, the case for taking action is overwhelming. In Leeds, however, there is heartening evidence that the trust is responding to these problems positively and managing to reduce and mitigate the personal and other effects of out of area treatments.

A great deal remains to be done, however, and while any out of area treatments, which are the result of inadequate bed capacity in Leeds continue, the need for action must be a priority. 

Jeremy Pritlove was previously mental health development manager at Leeds social services department, and retired from that post in 2004. Before holding that post, he was a mental health social worker in Leeds. He is currently a member of Leeds Hospital Alert, a local independent health services monitoring group.

References
Healthcare Commission (2004) Ratings 2004: Out of catchment area treatments (adults). London: Healthcare Commission.
Killaspy H (2010) Quoted in ‘Millions wasted on treating mentally ill away from their communities’. The Guardian, Society, 14 April 2010.
Leeds Hospital Alert (2009) Out of Area Treatments in Mental Health: The Leeds situation 2004 to 2008. Available at: www.leedshospitalalert.org.uk or from Leeds Hospital Alert, The Cardigan Centre, 145/149 Cardigan Road, Leeds LS6 1LJ.
Mountain D, Killaspy H & Holloway F (2009) Mental health rehabilitation services in the UK in 2007. Psychiatric Bulletin 33 215–218.
Royal College of Psychiatrists (2010) PCTs ‘wasting millions’ on out-of-area treatments, reveals RCPsych (14 April 2010).
Ryan T & Rayne M (2007) Working with the independent sector and managing out of area treatments. Mental Health Review