Guidance

Out of area placements in mental health services for adults in acute inpatient care

Published 30 September 2016

The government has set a national ambition to eliminate inappropriate out of area placements (OAPs)^{[footnote 1]} in mental health services for adults in acute inpatient care by 2020 to 2021. This definition of OAPs has been developed following significant stakeholder engagement to enable progress against the ambition to be monitored. It is aimed at providers, commissioners and users of local adult inpatient acute mental health services in England.

It is intended to support providers and commissioners in accurately monitoring and reducing their use of OAPs and to help providers submit accurate information on OAPs to national data collections. It will also be of interest to those using mental health services and who may be placed out of area for their care.

Out of area placements

An ‘out of area placement’ for acute mental health in-patient care happens when:

A person with assessed acute mental health needs who requires adult mental health acute inpatient care ^{[footnote 2]}, is admitted to a unit that does not form part of the usual local network of services.

By this, we mean an inpatient unit that does not usually admit people living in the catchment of the person’s local community mental health service and where the person cannot be visited regularly by their care co-ordinator to ensure continuity of care and effective discharge planning.

Patients should be treated in a location which helps them to retain the contact they want to maintain with family, carers and friends, and to feel as familiar as possible with the local environment.

Sending providers ^{[footnote 3]} are to determine if a placement is classed as an OAP. The definition necessarily allows providers to apply knowledge of local catchment arrangements and the patient’s circumstances in taking a decision if a placement is an OAP. OAPs can occur within one NHS provider, in other NHS providers, or independent sector providers (ISPs).

Placement may occasionally be considered appropriate. Possible reasons have been outlined below.

Out of area placements decision tree

This is for the sending provider to use when determining whether an admission is an out of area placement:

An out of area placement may be appropriate when:

• the person becomes acutely unwell when they are away from home (in such circumstances, the admitting provider should work with the person’s home team to facilitate repatriation to local services as soon as this is safe and clinically appropriate)
• there are safeguarding reasons such as gang related issues, violence and domestic abuse
• the person is a member of the local service’s staff or has had contact with the service in the course of their employment
• there are offending restrictions
• the decision to treat out of area is the individual’s choice e.g. where a patient is not from the local area but wants to be near their family and networks

This list is not exhaustive. There are other reasons why treatment in an out-of-area unit may be appropriate. In these cases discharge and/or return to an appropriate local unit should be facilitated at the earliest point.

An out of area placement that is solely or primarily necessitated because of the unavailability of a local acute bed will not meet the criteria for being appropriate.

Classification of out of area placements:

Classification of an out of area placement will be in 2 parts:

1. The main measure of OAPs: a yes / no element that captures whether or not the person has been admitted inappropriately to a bed outside their local area, meaning, to an inpatient unit that does not usually receive admissions of people living in the catchment of the person’s local community mental health service and where the person cannot be visited regularly by their care co-ordinator to ensure continuity of care and effective discharge planning.
2. A supplementary measure that captures the distance travelled from home.

Patient experience

For people using services, an improved service without inappropriate out of area placements means that:

• people should be admitted to a unit within the catchment area of their local community mental health service where they are known and their care coordinator can visit them regularly
  • this should help ensure people can be supported to recover, helped to get home as soon as possible and given the right support once they are home to continue recovering
• placements should be in a location that helps people to retain the contact they want to maintain with family, carers and friends, and to feel as familiar as possible with the local environment
  • in most cases we expect this location to be within the catchment area of a person’s local community mental health service - however, a person may request admission outside of the catchment area of their local community mental health service, for example, if another area is closer to family, carers and friends
• if a person is out of area, there should be regular ^{[footnote 4]} reviews and assessments focussed on enabling the person’s return to their local service (see comment above about personal circumstances) as soon as possible, ensuring minimum disruption to care

Providers should also be aware of the NICE guidance published in August 2016: Transition between inpatient mental health settings and community or care home settings. This should be referred to for guidance on out of area placement and what should be done to support a person placed out of area.

Annex A: Flowchart description

The chart begins with: How to decide whether an admission is an Out of Area Placement (OAP)

1. The patient is being admitted by their home provider to an inpatient unit that usually receives admissions for people living in the catchment area of the person’s community mental health team (CMHT)

a) Answer: Not an Out of Area Placement (Best Practice)

2. The patient is being admitted to an inpatient unit within the person’s home provider, but not in the catchment area of the person’s Community Mental Health Team(CMHT)

a) Answer: Not an Out of Area Placement if the patient’s care coordinator is able to visit them as often as stated in their trust’s policy for patients who are admitted locally (Not best practice, but not an OAP)

b) Answer: Is an Out of Area Placement if the patient’s care coordinator is not able to visit them as often as stated in their trust’s policy for patients who are admitted locally

3. The patient is being admitted to an inpatient unit in another provider

a) Answer: is an Out of Area Placement

1. The term ‘out of area placements’ replaces the term ‘out of area treatment’ (OAT) in the Mental Health Services Data Set v2.0. ‘Out of area treatment’ is a retired term in NHS Data Model & Dictionary, as it is associated with non-contract activity. Out of area placements are also referred to as ‘out of area admissions’ in NICE guidance. ↩

2. This definition concerns NHS commissioned and funded non-specialist adult acute mental health beds only. The scope includes adult and older adult (functional) acute and psychiatric intensive care unit (PICU) beds. ↩

3. the sending provider is the provider that has taken the decision to place someone outside of the usual local network of services. ↩

4. The frequency of reviews will depend on the circumstances and type of placement but will be a minimum of weekly with many places reviewing much more frequently. ↩