Investigation report: Mental health inpatient settings - out of area placements

The Mental Health Bill, which was introduced to Parliament on the 6th November 2024, contains a number of provisions that aim to ensure that the patient’s wishes and preferences, and those of their family and carers, play a more central role in decision making. Key examples include: 1) Care and treatment plans : Under the Bill, all patients, excluding those under very short-term sections, will receive a statutory care and treatment plans. The Bill requires that the patient’s clinician consults with the patient and those who care for the patient’s welfare (e.g. family and carers), among others, when preparing and reviewing the plan. The contents of the care and treatment plan should comprehensively cover what is needed to ensure that the patient’s needs are met during and after their hospital stay. We will set out details of the content required within the plan in regulations. We anticipate that this will include, information about a patient’s wishes and feelings regarding their care and treatment and details of any individuals with a relationship or other connection with the patient or individuals to whom the patient’s care and treatment plan is relevant. For example, relatives or those who may be providing care or treatment after discharge. 2) Advance Choice Documents/ advance decision making: The Bill puts ‘Advance Choice Documents’ (ACDs) on a statutory footing. These provide a place for people to set out their wishes, feelings, decisions, values and beliefs when they are well. This is so the ACD can later be used to inform practitioners’ decisions around their assessment, admission and treatment in mental health hospital, if they experience mental health crisis and are too unwell to express these things at the time. Wishes and preferences may include the treatments they want and don’t want, based on their past experience, and who they want to be consulted on their care and treatment e.g. family or carer, if they lose capacity or competence. To encourage individuals to make an Advance Choice Document, the Bill places duties on health commissioners to inform people of the opportunity to make an Advance Choice Document, while they are well, and to offer support. To ensure a person’s Advance Choice Document has impact, the Bill creates a statutory framework that gives weight to the contents of a person’s Advance Choice Document as well as any other advance statements or advance decisions. 3) Clinical checklist: The Bill includes a new clinical checklist that requires clinicians to take steps when deciding a patient’s treatment. For example, the clinician must, among other things, support the patient to take part in decision making about their treatment, consider their wishes and feelings - including those in an Advance Choice Document - and the relevant views of anyone named by the patient as someone to be consulted with e.g. family members or carers. The aim of this is to make clinical decision making more patient centred. Actions planned to deliver safety recommendation: Delivery of the Bill. By when: Subject to Parliamentary timing. Organisational lead: DHSC. Resources in place to deliver actions: Dedicated Bill team. Delivery of revisions to the MHA Code of Practice. By when: 1- 2 years after Royal Assent of the new Act. Organisational lead: DHSC. Resources in place to deliver actions: Dedicated Bill and Implementation teams. Other dependencies identified: Dependent on passage of the Bill. Response received on 24 February 2025.

DHSC and NHSE are leading on the delivery of several actions which will contribute to addressing the safety recommendation, as outlined below. The 10 Year Health Plan The 10 Year Health Plan will set out our plans to improve health and social care for the benefit of patients, staff and the wider public. An important part of this will be how the integration of services, including the accountability & oversight and financial flow arrangements, can work better to drive value for patients. This also involves developing a vision for what effective, integrated care should look like by 2035 for people living with one or multiple long-term conditions (for example mental health conditions). Additionally, there will be a review of the current approach to accountability and oversight to determine whether it is fit for the future and can drive improvement and collaboration in our healthcare system. Tools for Financial Integration Financial integration via Section 75 arrangements allows for the pooling of budgets, sharing of resources and delegation of functions across NHS bodies and LAs. This is one of the important enablers for integration, and DHSC are undertaking a review of s75 arrangements to consider if there are changes we can make to the legislation to facilitate not only its greater use but also its ease of use. Recent announcements on reform and investment There have been announcements recently regarding reforms and investments to improve adult social care. This includes the independent commission into adult social care, which will be split over two phases and will set out a vision for adult social care, with recommended measures and a roadmap for delivery. An £86 million boost to the disabled facilities grant was announced for financial year 24/25, supporting people to remain in their home with a reduction in hospital admissions which could impact the requirement for mental health out of area beds. On 30 January, the government published its 2025 mandate to NHS England, laying the foundation for longer-term reform as part of the health mission. On the same day, NHS England published the NHS operational planning guidance, which set out the priorities for 2025/26. Together, these support addressing the safety recommendation through as follows: 1) A reduction of the number of targets for the NHS means NHS England has reduced the number of national priorities for 2025/26, giving local systems greater control and flexibility over how local funding is deployed to best meet the needs of their local population, which can help support system integration. 2) The mandate specifically sets out the need to improve patient flow through mental health crisis and acute pathways. The 2025/26 operational planning guidance is clear that ICB’s are expected to meet the Mental Health Investment Standard (MHIS) and work with providers to ensure that system discharge plans include mental health acute pathways to reduce average lengths of stay in the adult acute mental health pathway, improve local bed availability, and reduce the need for inappropriate out of area placements. Mental Health Funding Allocations The NHS is committed to reducing inappropriate out-of-area placements (OAPs) for mental health patients due to the associated risks, including higher rates of suicide following discharge and the susceptibility of out-of-area care to a closed culture which can have detrimental impact on quality and safety of care. All ICBs have published plans to localise inpatient care by 2026/27 under the national Commissioning Framework, improving both care quality and value for money. To support this, £75 million has been allocated in 2025/26 to assist systems and NHS-led Provider Collaboratives (PCs) in reducing one or more of the following: OAPs in Acute Care or Psychiatric Intensive Care Units (PICUs) Mental Health Learning Disability and Autism inpatient rehabilitation far from home Placements outside Natural Clinical Flow (ONCF) in Adult Medium and Low Secure and Children and Young People Inpatient Services. Neighbourhood Mental health Centres In addition, in summer 2024, NHSE launched 6 pilot neighbourhood mental health centres that comprise of a team of people from existing mental health services in that locality from health, social care and the voluntary sector. The team and associate local partners will work together to deliver a service 24 hours a day, 7 days a week with open access for anyone who requires mental health support. The aim is for these centres in the heart of the community to be firmly connected to both primary and specialist services which can be drawn on as required. A key feature of the model is Continuity of Care whereby the same team will support people with serious mental illnesses throughout all stages of their interaction with services, whether that be crisis support, psychological and social care support, or employment or housing support. The centres are based in people’s local neighbourhoods with the aim of reducing waiting times, hospital admissions and the need for OAPs. Additional Measures DHSC officials will work with officials at MHCLG to consider opportunities for collaboration to improve the way that mental health and housing services work together. Actions planned to deliver safety recommendation: 1) Ongoing preparation on the 10 Year Health Plan includes working groups considering the integration of services, and the implications for accountability & oversight and financial flows. Integration: Developing a vision for how the NHS can evolve to provide responsive, joined-up care to better support individuals with single or multiple long-term conditions (i.e. mental health), or complex health needs, who may require frequent, ongoing engagement with the NHS. This vision must shift to an integrated model where services work closely together, ensuring that patients experience improved continuity, coordination, and comprehensive support throughout their healthcare journey Accountability & oversight: Reviewing the current approach to accountability and oversight to determine whether it is fit for the future and can drive improvement in our healthcare system. Work will be focused on clarifying roles and incentivising the right behaviours and ways of working. Financial flows: Evaluating the finance and contracting implications of the 3 shifts, and identifying how these will need to change over the coming years. This includes considering how financial flows should change to achieve the emerging vision of the 10 Year Health Plan, improving patient outcomes, experience and choice. By when: Spring 2025 (tbc). Organisational lead: DHSC. Resources in place to deliver actions: Eleven working groups are supporting policy development for the 10 Year Health Plan. 2) S75 partnership arrangements review – Reviewing the legislation to see if there are any changes we can make to enable further use. As part of this we are considering if we should widen the organisations that can enter into s75 arrangements to improve join up amongst public services and support a shift towards models of delivery that focus on preventative proactive care. By when: TBC. Organisational lead: DHSC. Resources in place to deliver actions: DHSC place team delivering s75 review. 3) Announcement in January 2025 of £86 million boost to the disabled facilities grant for financial year 24/25. This funding will support people to remain in their home with a reduction in hospital admissions which could impact the requirement for mental health out of area beds. By when: 2024/2025. Organisational lead: DHSC. Resources in place to deliver actions: £86 million boost to the disabled facilities grant for financial year 24/25. 4) Social Care Reform: We are launching an independent commission into adult social care as part of our critical first steps towards delivering a National Care Service. The Commission will be split over two phases and will set out a vision for adult social care, with recommended measures and a roadmap for delivery: Phase 1 – reporting in 2026, will focus on how we can make the most of existing resources to improve people’s lives over the medium term. These reforms will help build the foundation for a National Care Service, support NHS goals and improve local services, making recommendations for medium term improvements. Phase 2 – reporting by 2028, will make longer-term recommendations for the transformation of adult social care, addressing demographic change, how services should be organised to deliver this and how to best create a fair and affordable adult social care system. We will also be taking forward a range of initiatives in 25/26, including funding more home adaptations, promoting better use of care technologies, and professionalising the adult social care workforce. By when: 2028. Organisational lead: DHSC. Resources in place to deliver actions: DHSC Adult Social Care teams working on social care reform. 5) All ICBs have published plans to localise mental health inpatient care by 2026/27 under the national Commissioning Framework, improving both care quality and value for money. Funding has been allocated to support systems and NHS-led Provider Collaboratives in reducing one or more of the following: OAPs in Acute Care or Psychiatric Intensive Care Units (PICUs). Mental Health Learning Disability and Autism inpatient rehabilitation fare from home. Placements outside Natural Clinical Flow (ONCF) in Adult and Children and Young People Medium and Low Secure services. By when: 2026/27. Organisational lead: Integrated Care Systems. Resources in place to deliver actions: £75 million has been allocated in 2025/26 to assist systems and NHS-led Provider Collaboratives (PCs). 6) The Government’s 2025 mandate to NHS England reflects a reduced number of targets for the NHS in the mandate, which means NHS England has reduced the number of national priorities for 2025/26, giving local systems greater control and flexibility over how local funding is deployed to best meet the needs of their local population, and therefore supporting system integration. The operational planning guidance published by NHSE is clear that ICB’s are expected to meet the Mental Health Investment Standard (MHIS) and work with providers to ensure that system discharge plans include mental health acute pathways to reduce average lengths of stay in the adult acute mental health pathway, improve local bed availability and reduce the need for inappropriate out of area placements. By when: 2025/26. Organisational lead: Integrated Care Systems. Resources in place to deliver actions: Allocated resources to systems. Response received on 24 February 2025.