Reducing out of area placements via service redesign and referral management

Key benefits and outcomes

• 42 per cent decrease in inappropriate children and young people's out of area placement  days between 2023 and 2025.
• Streamlining referral processes has helped avoid unnecessary inpatient admissions.
• Efficiencies from the new referral process has freed up funds to invest in new outpatient and community services.
• Reduced admissions has allowed the repurposing of beds to meet wider complexity of needs and bring more children and young people close to home.

What the organisation faced

Workforce capacity issues in the East of England region meant bed numbers had reduced, both within NHS and independent sector services. This had led to a large number of children and young people (CYP) being sent out of the region for inpatient mental health care. 

What the organisation did

Mental health services in the region launched a provider collaborative in July 2021. The collaborative operates as the commissioner for specialist mental health services, focusing on tackling inequalities and moving care closer to home.  It connects six NHS mental health providers and local independent providers in the region, with Hertfordshire Partnership University NHS FT acting as lead provider,

The provider collaborative designed a programme to better understand what was driving OAPs. It began by pulling all inpatient referrals centrally into a ‘patient flow hub’ and gathering operational and clinical data such as referral patterns, locations of services where patients were being admitted, variations in length of stay and the nature of the conditions patients were presenting with. Using this information, staff at the collaborative were able to explore whether some patient groups might be better served by a service other than inpatient provision, as well as identifying which areas of the CYP service needed to be prioritised. 

It quickly became apparent to managers that a key driver of bed closure was difficulty recruiting staff across different types of professions, due to levels of acuity of patients as well as services being less attractive due to the distance from London and rurality of some units.

They needed to upskill staff, provide increased support and better understand why some staff were dealing with disproportionate levels of complexity within their roles.

The collaborative identified what training was required and developed training programmes so that patients with very challenging behaviours were distributed more evenly across the available local services. 

A Culture of Care programme was implemented in some units, which helped improve the therapeutic nature of wards. Interventions include creating a more sensory-friendly environment and reviewing reasonable adjustments for people who are neurodiverse. This has helped create a better environment for patients and staff, with a plan to roll this out consistently across the region.

A second strand of the strategy was to use funds freed up by reducing the number of patients in OAP and using local beds more efficiently to invest in new services. These include an eating disorder day service provision, intensive community support and intensive home treatment teams for general children’s and adolescents’ services. The new services are standardised to some extent, for instance the majority of areas have a home treatment team, but they are also flexible enough to accommodate local needs. This means that while services respond to local need, they are sufficiently similar that they can be assessed for their quality and safety performance under a uniform approach. 

In each case, pathway redesign has been led via a clinical development and design group overseen by the clinical director that leads for the care area in question, but with representation from each organisation. The collaborative has used quality improvement methods to test and roll out new services, starting with small scale pilots and then implementing new service models across wider areas once an evaluation has demonstrated an impact. This means that where a new service model has not yet let to an anticipated outcome, it can be developed further and tested again before wider roll-out. While the membership of the collaborative is limited to NHS organisations, independent sector organisations have been included in discussions about pathway development as providers of local services. 

Results and benefits

From the outset, the collaborative has operated under the general principles of bringing care closer to home, outside of hospital, improving quality and safety and learning from each other via peer challenge and peer review. This has led to a more streamlined approach, and a local provider sector that asks itself challenging questions from the basis of strong clinical leadership. 

MHSDS data shows that CYP OAP days have reduced significantly across the system in recent years. There was a 42 per cent decrease in the inappropriate CYP OAP days when comparing June-August 2023 and June-August 2025, from 960 to 555. There were 10 cases reported as being active at the end of August 2025, compared to 15 in August 2024 and 10 in August 2023.

Due to the success in reducing inappropriate OAPs for children and young people, the collaborative has started to repurpose beds to support those with more complex needs, as outlined in NHS England’s 2023 Children and Young People Mental Health, Learning Disability and Autism Inpatient Review. This includes CYP with complex eating disorders and those who would have been in what is known as Psychiatric Intensive Care Unit (PICU) beds. 

Overcoming obstacles

It was not always easy to achieve agreement across six different organisations with different priorities, and the pace of change was difficult across each organisation. Clinical directors have busy roles and if their job plans do not reflect the priorities of the provider collaborative, then this can be seen as additional work. 

Trust between organisations within the collaborative is critical. Ensuring that strong levels of trust was in place was particularly important when the collaborative was setting up the flow hub and giving over responsibility to the hub to centralise referrals and allocate to beds.

Takeaway tips

• Gather high-quality baseline data to inform service redesign plans.
• Build in clinical leadership at every step of pathway redesign activity.
• If appropriate, consider using contractual levers to focus attention on areas of underprovision.
• Use quality improvement methods to test and refine new interventions at a smaller scale prior to full roll-out.
• Ensure that patients and carers are involved and are able to contribute meaningfully, both to new developments and to the evaluation of new schemes.