Out of sight, out of mind?

I was interested to read the Royal College of Psychiatrists briefing paper on ‘eliminating inappropriate out of area placements in mental health’. I am a consultant Clinical Psychologist working within a commissioning team (employed by the NHS). I have the responsibility of: Reviewing all existing out of area placements for people with diagnoses of personality disorder who were originally from the South London area; To assess the quality of interventions offered; and to develop a strategy to reduce the use of these placements. 

Overall, I thought the Royal College report was sensible. It outlines the government’s aim to eliminate ‘inappropriate out of area placements’ – a placement is considered inappropriate if there is not available bed within area, so therefore an out of area placement would never be viewed as appropriate. The report detailed current barriers in achieving this, including the current workforce shortage in the NHS and bed flow. The report stresses a need for there to be a systems approach to take concrete and urgent action to resolve this. It gives recommendations, including increasing the therapeutic value of admission, improving workforce shortages and improving patient flow. 

I couldn’t help thinking that these recommendations were a little ‘concrete’ in themselves, and perhaps a more nuanced formulation of the difficulty is required. Since being in this role, I have tried to make sense of the problem, to inform the strategy going forwards. So why are people sent out of area in the first place? Referrals to my team indicate this is usually because it is not possible to discharge the patient from hospital due to risk, or not having appropriate accommodation. It’s become apparent that these patients are often excluded from the psychological treatment on offer in the community, perhaps for being ‘too chaotic’, being unable to attend appointments, or having difficulties associated with violence or substance misuse. We are all well aware of the term ‘they slip through the gaps’. It was particularly stark to me that these patients are profoundly detained yet do not fit into our categories. Overly stretched staff appear frightened for (or of) these patients and understandably desperate for help. There is often a fantasy that the patient will receive gold standard treatment in these units, perhaps informed by glossy pamphlets. Once the patient has been sent out of area, there are very few structures in place to keep them in mind. It has been difficult to find a clinical team who will take responsibility for these individuals should the placement break down. The patients effectively become out of sight out of mind. In an NHS system which is strained, I have wondered whether there could be an unconscious ‘secondary gain’ that the most distressed patients effectively disappear. 

I would agree with the Royal College that we need to commit to action including to improve flow and workforce. But I think that a more radical change in the system is required. I was at a conference recently where this was discussed. When we were asked to think as a group how we can act to change the problem, several delegates placed the responsibility within commissioning teams and suggested ‘commissioners need to educate themselves on the problem’. With confidence, one delegate stated something along the lines of ‘commissioners have senior staff but they aren’t clinicians, they don’t understand clinical issues’. I found myself feeling defensive and exclaimed ‘I’m a Clinical Psychologist working as a commissioner’. I questioned whether by externalising the problem in this way, it prevents us from considering how we contribute to it. My voice wobbled when I explained the dilemma of a patient telling us ‘if I don’t go to the unit I’ll kill myself’ having been promised a referral to an inpatient unit and told that it ‘just needed to go to the funders’.

As psychologists, rather than looking outwards, perhaps we should look inwards. How can we reduce the barriers for access for these patients? Do we really need all the exclusion criteria for our therapeutic services? If the patients are ‘too chaotic’ or risky for traditional treatment in the community, what are we doing to support the patients to get to a point where they can engage? 

So, what are we doing as a commissioning team? We are re-investing money we saved, by bringing patients home, into a local service which bridges the gap from acute services and the community. With colleagues and service users on the ground we have developed a service which will provide psychologically informed in-reach to the wards, with intensive transitions work on discharge, providing continuity of care. This service will have a focus on relationships rather than restrictions.  

Dr Emily Turton, Consultant Clinical Psychologist, South London Partnership Complex Care Programme

Read our interview with Dr Turton