Introduction to 'Close to Home', NDTi’s review into out of area placements

Most of us just want to be at home when we are unwell. In our own bed, under our own duvet, surrounded by our own stuff. When that’s not possible, because our health is more seriously affected, we want care and treatment close to home, in an area we know and where the people we love can visit often and easily. These connections help us recover and lead us back to the everyday lives we want to lead.

But for many, this isn’t an option. People who need support for mental health conditions are far more likely to find themselves receiving care and treatment many miles from home. It might be because the local inpatient ward is full or because the planned treatment needed is specialist and only available in a certain part of the country. The reasons are complicated, but the conclusion is clear: “the inappropriate use of out of area placements challenges individuals’ rights and the chances of positive recovery”.

The quote is from our paper “Close to Home: review and recommendations for reducing out of area placements for adults with mental health conditions”. The report, written by NDTi Associate Edana Minghella, provides an overview of the policy, issues and costs – to the person themselves as well as the public purse. Crucially, the paper also provides a way forward, one that draws upon the NDTi’s long history of working to make sure people with learning disabilities and autistic people, can be brought back into their communities and supported to lead fuller lives and keep well.

Small Supports is the latest programme designed to do just that. Its ambition is to improve the range of community supports available to better meet the needs of autistic people and people with learning disabilities who are in hospital or at risk of being admitted for treatment for their mental health conditions though mainly it is because their behaviour challenges the services that are currently supporting them: people who are part of the Transforming Care Programme.

There are striking parallels in the concerns and issues raised about care and treatment provided far from home and, equally, lessons that can be shared and learned. Not least the need for partnership working across the health and social care system, including working with the voluntary sector, small scale bespoke providers and, importantly, people with lived experience and their families. NDTi’s work in this area provides relevant experience that Edana, with her own mental health specific background, has applied to Close to Home.

NDTi recruits, trains and supports people with learning disabilities, autistic people and family carers for NHS South East and South West. We now have over 50 experts who use their lived experience in reviews to challenge the care and treatment of adults and young people placed in hospitals across the country and to help prevent their admission.

We know from our Experts by Experience that care and treatment and a successful return home can be compromised and delayed by a series of factors that are not always medical. These can include:

• A lack of suitable accommodation in the community and a similar lack of community support staff with the appropriate level of skills

• Ongoing challenges between health and social care in co-ordinating services and support (including financial agreements)

• Changes in staffing and the consequent demand for new formulations

• A restriction on personal possessions and a lack of meaningful activities that lead to people’s behaviour deteriorating through boredom but can be interpreted clinically

• The absence of effective advocacy

• An environment that’s unsuited to people’s needs.

We know from Panorama and other media reports that there is also a risk of seclusion, restraint and punitive action to control behaviour that can amount to physical and psychological torture. For these reasons we support the legal challenge launched last week by the Equality and Human Rights Commission against the Secretary of State for Health and Social Care for the systemic failure to protect human rights.

What we don’t know is how well or not the rights of people with mental health conditions who are not autistic nor have learning disabilities are respected when receiving care and treatment a long way from home. The information is limited and mainly about placements rather than people.

In Sight In Mind, the joint report from Rethink Mental Illness and the Royal College of Psychiatrists will help shed more light. The report, which is due soon, presents new evidence on the mental health rehabilitation system and makes a series of recommendations for its future. Again, the focus is on the importance of receiving such care close to home. The two papers work well together, with both stressing the need for a whole system approach.

Close to Home complements the above work by providing a clear set of recommendations for local health and social care system on how to reduce out of area placements whether they are used for rehabilitation or because of a lack of local available beds. We always need to remember that using the terms beds and placements obscures their impact on people, which is why co-production underpins each step of our suggested way forward.

The message of both papers is clear, after all these years, change is still urgently needed.

Kate Linsky has worked in the public sector for over 25 years at local and national level, including senior roles with the Audit Commission and the Local Government Association.