Key points
Inappropriate out of area placements (IOAPs) have a significant emotional, economic and health impact on patients and carers, and negatively impact patient outcomes.
Staff working in mental health services are also at risk of ‘moral injury’ from the need to send patients out of area, as it does not deliver a standard or care that staff believe is acceptable.
Data on IOAPs has been published since 2016. Figures show levels of IOAPs have remained stubbornly high throughout this period, costing the NHS in England in excess of £164 million in 2023/24 for adults alone, alongside driving wider inefficiencies for healthcare providers within and beyond mental health.
Systems and providers are addressing these challenges by intervening at different points in the pathway to reduce IOAPs in line with the NHS’s focus on prevention and providing community-based care.
Reducing IOAPs requires improvements in capacity and flow across the mental health pathway. Shifting a greater share of resources into community provision and better integration with housing and social care, as outlined in the Community Mental Health Framework, help keep people out of hospital, reduce pressure on limited bed availability and reduce the risk of readmission, lengthy waits in emergency departments and delayed discharges.
But some patients will still need to be admitted to hospital. There is a variation in available beds per head of population, and in some areas gaps in capacity that require capital investment to fix, beyond what has already been made available specifically to reduce IOAPs.
This report outlines the impact of IOAPs on patients, families, mental health services and the wider health and care system; presents ways of responding to these challenges; highlights case study examples of positive practice; offers recommendations for national policymakers and identifies approaches for providers and system leaders to implement when looking to address IOAPS.
Inappropriate out of area placements can have severe consequences for patients, carers and the wider system. This report highlights that impact, presents ways of responding to the challenge and provides examples of positive practice.
Introduction
Out of area placements (OAPs) for acute mental health inpatient care occur when a person with acute mental health needs is admitted to a unit outside the usual local network of services. They are considered ‘appropriate’ in certain situations, such as where a person has become unwell away from home, wishes to receive treatment closer to relatives, or where clinical, safeguarding or privacy reasons for providing care elsewhere apply (1).
In adult care, out of area placements that do not fit these criteria are classed as ‘inappropriate’ and have been under scrutiny for some time in England. In 2016, the Department of Health and Social Care (DHSC) set an initial commitment to eliminate inappropriate OAPs (IOAPs) in acute adult mental health inpatient services in England by 2020/21 (2). Despite the hard work of system partners, this target was not met and work has continued to reduce the number of adult patients being sent out of area. No similar target existed for children and young people’s (CYP) mental health services, where problems with IOAPs also endure. The Medium Term Planning Framework does include the goal of reducing or maintaining at zero the number of inappropriate out of area placements by 2028/29. When an OAP is inappropriate, the consequences can be severe for patients, carers and the wider system. The patient is at risk of isolation; breaks in care continuity; separation from friends and family; disrupted access to school or college in the case of children and young people; and greater challenges in re-integrating with their local services on discharge. Carers, family members and friends experience significant distress, inconvenience and expense as they try to maintain contact with loved ones who have been placed in distant inpatient units.
For provider organisations and health systems, IOAPs can represent a significant expense, as well as posing delivery challenges (3). IOAPs are usually procured via spot purchasing (where a bed is procured on an individual basis) and can be a more expensive way of purchasing care than procurement via block contract. Having a patient admitted at distance creates logistical challenges for staff, particularly ensuring care continuity during the inpatient stay and at the point of discharge. The nature of these challenges reflects the fact that IOAPs are a symptom of wider issues that exist along the mental health care pathway, relating to flow, length of stay, bed numbers and capacity in the community in particular.
How many mental health beds is the correct number and how far it is possible to reduce them have long been debated in the sector: from the belief it is possible to achieve a model similar to the Trieste model in Italy that has almost no use of inpatient beds, to those who argue that with capacity regularly well over the recommended 85 per cent level in most trusts, and IOAPs not yet having been eliminated, more bed capacity must be made available.
These issues were discussed in the 2016 report Old Problems, New Solutions from the Commission to Review the Provision of Acute Inpatient Psychiatric Care for Adults (4), and an analysis by The Strategy Unit in 2019 found that while bed numbers had fallen by 73 per cent in the 30 years preceding the report, the reduction in bed numbers was managed by a combination of admitting fewer people and use of IOAPs in some regions (5).
High numbers of IOAPs are not in the interests of patients, carers or providers. The capacity challenges that lead to IOAPs can also result in increased waits in emergency departments and the placement of patients with mental health needs in beds intended for physical care, as providers wait for mental health beds to be sourced. These problems therefore have a wider impact across the NHS.
The 10 Year Health Plan commits to three shifts: moving care into communities, making better use of technology, and increased prevention. Improving prevention and treating a greater share of patients in the community can help reduce IOAPs. Recently announced reforms, including the abolition of NHS England, need to ensure clear lines of accountability to reduce IOAPs, particularly given the financial impact of them on providers and health systems, so that they drive progress in this area rather than inhibiting it.
This report has been produced by the NHS Confederation’s Mental Health Network and the Royal College of Psychiatrists to support mental health service providers to reduce IOAPs in mental health care. It draws from evidence provided by leaders in the NHS, social care and the voluntary and independent sectors and experts by experience, focusing on IOAPs for working-age adults as well as children and young people. Through discussions we sought to understand the challenges professionals face in reducing general acute IOAPs, and the work underway in different parts of the health and care system to ensure that as few people as possible are sent out of area inappropriately.
Here we present the findings from these discussions, outlining the impact of IOAPs on patients, families, mental health services and the wider health and care system. We also present ways of responding to these challenges and case study examples of positive practice within the sector. Finally, we make recommendations for national policymakers and identify approaches that providers and system leaders can implement when looking to address the issue of IOAPs.
Positive practice across the mental health pathway
There are a number of examples of positive practice implemented by providers and systems seeking to improve flow, avoid admissions and remove barriers to discharge, thereby reducing IOAPs. These and others are included in more detail in this report:
Avoiding admissions within and out of area
- Home-based crisis resolution and intensive treatment teams, including the model used in Tees, Esk and Wear Valley, can support people in urgent need of care in a home environment, avoiding admissions.
- In Somerset, a ‘single front door’ is being used to direct patients to the most appropriate service and to ensure opportunities to intervene are not missed.
Admission
- The East of England’s mental health provider collaborative has developed a new single referral route into intensive day services and community services to ensure the most efficient use of available resources.
- Independent sector provider Priory Group has partnered with the local health system in Preston, Lancashire, to develop a new 12-bed in-area inpatient service, saving £250,000 in reducing length of stay alone.
Discharge planning
- Avon and Wiltshire Partnership worked with local authorities to check the quality of care packages to ensure appropriate plans are in place when patients leave hospital, saving £7.3 million over three years.
- Open Mental Health provides a lead accountable organisation managing referrals for support in Somerset, along with strong collaboration from social care, this has minimised delays to discharge.
- In Oxfordshire, a supported housing campus provides assertive support, accommodation, and in-reach discharge planning for those who are clinically well for discharge, but have significant, ongoing needs which can delay their discharge.
Understanding the current picture for IOAPs
The issue of IOAPs is complex and impossible to separate from wider structural challenges within the mental health sector and the wider NHS landscape. However, in seeking to understand these issues, the impact of IOAPs on patients and their families and carers must not be overlooked.
Impact on patients, carers and families
IOAPs are known to have a significant negative impact on patients. The Health Services Safety Investigations Body report into IOAPs warned that they could lead to anxiety, psychological stress, post-traumatic stress disorder and patients dying by suicide. Patients, families and carers described feeling that they were not listened to by staff and highlighted increased anxiety, frustration and anger, leading to harm for people and creating distrust in the system (3).
Separate interview-based research with young people and carers who had experienced an admission far from home found they had limited or no involvement in decision-making processes around admission and revealed challenges for patients in maintaining home contact and practical and financial challenges for visiting families.
However, some patients benefitted from being removed from unhelpful local environments and an ‘admission at distance’ provided respite for some families struggling to support their child (1).
Patients, carers and professionals described how people in inappropriate OAPs over long periods risked losing contact with family, friends and their local community, which makes reintegration more challenging after discharge. The clinical support provided post-discharge is a critical time that drives longer-term outcomes, particularly within the immediate 72 hours where risk of suicide is highest. Arranging follow-ups with patients in this period, when professionals have not been directly involved in their care and do not know the patient well, is more challenging and patients can be less likely to engage.
Where patients were placed out of area, it was harder for family and friends to support them in the run-up to discharge. Employment can be disrupted through the need to regularly travel long distances, with some having to leave the labour force entirely. Adult patients face the risk of losing their home, and children could experience significant educational disadvantage, particularly during the Key Stage 4 GCSE exam or A Level preparation period.
Discontinuities in professional support and personal relationships can increase the likelihood of relapse and disengagement from services. Professionals, patients and carers were united in the view that eliminating inappropriate OAPs must be a priority for the NHS. Although out of scope for this project, similar challenges were identified in relation to eating disorder beds and rehabilitation beds.
First-person accounts from a patient and a carer who experienced inappropriate OAPs show the significant impact that these placements can have on the patient’s recovery and on the wellbeing of both patients and carers.
First-person account: Zoe Mitchell
Zoe Mitchell has experienced out of area placements as a patient using mental health inpatient services and is a service user representative on our Mental Health Network’s board.
"I was in hospital for about three years and in two different out of area placements for a total of more than two years. One of these placements was about four hours away from my family, so it involved an eight-hour round trip for them to come and see me, and the other one was about an hour and a half away.
"In out of area placements, the continuity of support isn’t as good as when you’re in area, because you don’t have your family there, coming in every week or so to keep an eye on how you’re doing. There’s no overarching support network and you’re just left. I was in a placement up north in Warrington and I’m from down south. Even things like regional accents when you’re very unwell can be completely disorientating. It’s little things like this that people maybe don’t think about.
"I didn’t have a care coordinator for quite a long time, and that was hard because there was no-one looking out to see if the placement was actually helpful or whether it was having a negative effect. Once I finally got a hands-on care coordinator, who was a social worker, she realised how negative this out of area placement had been and transferred me back to an acute hospital in area and I was discharged within three months. That shows just how important it is to be within your support network and in a familiar environment, where you have people from the community team who can start to support you while you’re in hospital.
"You get very institutionalised in hospital and I would say this is more so when you have no connection to the outside community at all, when you’re essentially locked up and have no idea when you’re going to be leaving. Even things like Section 17 leave [authorisation from a clinician to leave the hospital under certain conditions as part of a recovery plan] are virtually impossible in an area that you don’t know. It's also about financial issues for your support network. My parents were luckily able to travel the eight-hour round trip, but there were many people when I was in hospital who didn’t see their family for months, if not years. I’m quite an advocate for saying no to out of area placements. Getting back into area, within that support network where you feel safe and have people looking out for you, is absolutely vital for long-term recovery."
First-person account: Rachel Bannister
Rachel Bannister is the chair of the Mental Health – Time for Action Foundation, a charity campaigning for increased funding and availability of mental health services.
“Our journey began when my daughter became unwell about ten years ago and we were referred to the local CAMHS service. She had symptoms of an eating disorder - she was also clearly depressed and anxious - and she deteriorated under outpatient care because they didn't have the resources and the staffing required.
“We had a two-month wait until a bed became available, 50 miles away from home. I'll never forget the drive there and handing her over to a team of clinicians who were lovely, and did everything they could, but it was horrific. On the drive home, I had to keep pulling over. I just felt depleted. I felt like a failure.
“She was there for ten months, a very long time to be away from those who love and care for you when you're so ill. It took her months to develop trusting therapeutic relationships and by the time she'd established those, she was sent back home. She deteriorated again but wasn't sick enough to be sent back to the same hospital and we had an emergency admission to a general paediatric unit, again with lovely staff, but they didn't have the skills to give her the support she needed.
“She was admitted to a specialist bed 100 miles away from home, then we had an admission that was nearer, but to a general adult unit, which wasn't right for her. She deteriorated again and was admitted to another inpatient unit, this time 300 miles away. There was no support to help us get to this hospital - luckily, we could put the £600 on our credit card to pay for the flights.
“The impact on the young person is pretty horrendous. The other thing was the impact on the whole family. I was up and down that motorway several times a week, but I had two younger daughters at home that also needed me, and sure enough, when she came out of hospital and was relatively stable, I became very ill myself. It's affected relationships across the whole family - even my parents. I had to give up work, but my husband was able to carry on working. If we were another family, without that level of financial stability, we might not be here. All the time, it's been a matter of luck, and that makes me feel very angry.”
What is the scale of the IOAPs problem and who experiences them?
Young adults are most likely to be sent out of area out of all age groups. In the year ending 31 March 2025, 43 per cent of new adult acute placements were for adults aged under 35. The age group with the highest frequency of new IOAPs over this period was those aged 25-29 years (290), followed by the 18-24 age group (243) and those aged 35-39 (229) (6).
Adult acute inpatients spent 164,166 days in IOAPs in the year to March 2025. This represented an increase of 46.7 per cent year on year (111,896). 1,785 new IOAPs in adult acute beds started during the year ending 31 March 2025. Of these, 70 per cent were in adult acute mental health beds, 27 per cent were adult psychiatric intensive care unit beds and 3 per cent were acute older adult beds. A little over half of these placements (54 per cent) were occupied by males.
Across all ages and bed types 5,649 new IOAPs started in the year to March 2025, which is a 4.8 per cent increase compared with the year to March 2024 (5,392). There were 524,615 IOAP bed days – a 16.3 per cent rise compared with the year ending in March 2024 (451,067) and 1,431 IOAPs remained active at the end of the year – a 1.4 per cent decrease compared with the year ending in March 2024 (1,451) (7) 1 .
The collection of IOAPs data changed in early 2024, moving from NHS England’s Clinical Audit Platform (CAP) to the Mental Health Services Data Set (MHSDS). As a result of this change, plotting long-term trends can be difficult. However, the pattern has been for an upward trend in IOAPs since the first wave of the Covid pandemic where numbers did briefly decline sharply.
In March 2024, when standalone reporting on IOAPs via the CAP ceased, there were 805 reported IOAPs for adults across the 41 adult acute inpatient mental health providers in England that submitted data (accounting for 72 per cent of organisations in scope) (8). This is a year-on-year increase of nearly 16 per cent, based on returns from 75 per cent of organisations. This figure compares with 684 IOAPs in March 2017, with a 84 per cent response rate.
As the number of placements at distance had increased, the proportion of those at a distance of 100km or farther away also increased.
In March 2024, 57 per cent of IOAPs were 100km or farther from the sender provider, compared with 26 per cent in March 2017. At the peak, in May 2023, 65 per cent of placements were at a distance of 100km or more. The proportion of IOAPs ending after 31 or more nights was 44 per cent in March 2024, compared with 20 per cent in March 2017 (8). Across this period, there was a steady increase in the number of people in contact with secondary mental health, learning disability and autism services, from 2.638 million in 2016/2017 to 4.129 million in 2024/25 (9)
2
The MHSDS dataset does include some information about the prevalence of IOAPs in children and young people aged 0-17 years. This data shows recent significant reductions in IOAP days. Analysis of the data by the Royal College of Psychiatrists found the number of IOAP days involving children and young people had fallen 14.7 per cent (42,391 to 36,147) between 2023 and 2024, with the latest figure standing at 29,736 in the year to March 2025. Work has been underway to reduce IOAPs in both adults and children, but the lack of detailed historical comparator data in the case of children and young people, and the changes in recording approach for data on adults, mean any apparent trends must be interpreted with caution.
These figures also mask the reality that people who are considered ‘in area’ can still be geographically far away from home. This is because the catchment area of a trust, and particularly a provider collaborative, can be large, so even though the placement is classed as ‘in a usual network of services’ it may still require a long travel time from the patients’ home.
Separate research conducted by the University of Nottingham into adolescent inpatient admissions out of area or far from home (greater than 50 miles or 80km) using data from the Royal College of Psychiatrists’ Child and Adolescent Psychiatry Surveillance System (CAPSS), found that between February 2021 and February 2022, within a sample of 279 13-17-year-olds, 38 per cent were admitted more than 100 miles [160km] from home and 8 per cent more than 200 miles [360km] from home. The most common diagnoses at referral were depression (34 per cent) and autism spectrum disorder (20 per cent), with other common referral concerns including suicide risk (80 per cent), emotional dysregulation (53 per cent) and psychotic symptoms (22 per cent). Of these, 41 per cent had waited one week or longer for a bed, with 55 per cent waiting in general hospital settings, ie. within an acute hospital rather than a mental health service provider. At six-month follow up, 20 per cent were still in hospital, with the majority of these in ‘at distance’ placements, which is defined in the research as more than 50 miles [80km] from home or out of region (10).
Chapter footnotes
How do IOAPs impact health and care systems?
System impacts of IOAPs can be understood in terms of their financial consequences for providers as well as the way they pose challenges within the mental healthcare pathway and for physical health and care services.
Financial and quality impact of IOAPs on providers
Having a high number of IOAPs has significant financial implications for mental health provider organisations.
In March 2024, the average daily total cost of an adult acute IOAP in England was £700, with average daily costs ranging from £555 in the north east and Yorkshire to £750 in London. The cost of IOAPs for adults for the year up to the end of March 2024 was £164 million, compared with £91.421 million for the same period in 2017/18, which is an increase of approximately 80 per cent. (8). Since only 72 per cent of relevant organisations participated in this data collection in March 2024, the true monthly cost of IOAPs is likely to be higher. This data does not form part of the new data collection and has never been collected for children and young people. We were not able to access separate figures for spot-purchased beds but the issue is significant, since funding diverted to paying for spot-purchased beds in distant providers is not available to invest in capacity locally, which would potentially prevent such admissions. Using spot-purchased beds located at a distance can meet urgent needs, but because of the nature of these services they can lack integration with community mental health services provided within the patient’s local system. It can also be challenging for the patient’s local provider to quality assure services provided via ad hoc spot-purchasing arrangements, although some health systems are developing solutions to this problem.
Drivers of IOAPs
IOAPs occur when demand for mental health inpatient beds exceeds supply within a local area and staff are forced to look further afield for a patient’s care. The reasons why this can happen are more complex than there simply not being enough beds locally. Between 2017/18 and 2024/25 there was a 60 per cent increase in the number of contacts with secondary mental health services. Providers and clinicians also tell us there has been an increase in the acuity that patients are presenting with and are more likely to be in crisis when accessing support. This has increased demand for inpatient beds, driving longer length of stays and delays to discharge due to complexity of need.
Factors also linked to increasing IOAPs are the gap between the demand for community-based services, including step-down provision, which are intended to prevent crises and reduce readmission, and the resources available to provide these. This can also impact on the confidence of clinicians to not admit or to discharge people.
Other factors such as the cost of living crisis; rising prevalence of mental ill health; staffing recruitment and retention challenges; and prolonged social isolation due to the COVID-19 pandemic have also been identified as drivers of IOAPs (11).
Lengths of stay have been going up for adult inpatients. The number of working-age adults discharged from an adult acute bed with a length of stay of 90 days or more has increased by 15 per cent when comparing January-March 2022 with January-March 2025 (12). Research conducted by the Care Quality Commission describes service providers reporting that patients admitted to inpatient mental health facilities appear to be more unwell on admission than in the past. This can lead to longer recovery times, making it harder for services to admit new patients (13).
Between January and March 2025, 3,350 adults aged 18-64, and 315 children aged 0-17 had been in hospital for 60 days or longer. Over the same period, 1,918 adults aged 18-64, and 256 children were discharged after stays of 90 days or more (12).
Data for March 2025 shows that 55,670 days of delayed discharge were identified where patients were clinically ready for discharge across all mental health services. This compares with 16,077 in April 2016, the first month for which data is available, which is a 216 per cent increase. Once the delayed discharge days for March 2025 with an unknown attributable organisation are excluded, 43 per cent were attributable to social care, 28 per cent to the NHS and 30 per cent to both the NHS and social care, in each case excluding housing (12).
NHS England also publishes data on the reasons recorded for delayed discharge days. The reason most frequently reported in March 2025 was ‘awaiting supported accommodation’ (24 per cent), followed by ‘awaiting a placement in a care home with nursing’ (13 per cent) and ‘awaiting a placement in a care home without nursing’ (13 per cent) (12).
UK Government guidance applying to England states that processes should be in place to identify people at risk of a delayed discharge at the point of admission or before (14). While numbers of inpatient mental health beds are declining across the board, a small number of mental health trusts have been found to consistently lack capacity to meet demand due to a variety of reasons including financial, workforce and estates constraints. (15). According to a 2024 analysis by The King’s Fund, with the exception of the time period coinciding with the COVID-19 pandemic (Q1 2020/21-Q4 2020/21), adult mental health bed occupancy continuously ran higher than the recommended bed occupancy rate of 85 per cent from the period when data collection began in 2010 (16).
Since the 2019 Strategy Unit report that showed a 73 per cent reduction in beds in the previous 30 years, available overnight NHS mental health beds have continued to trend downward, with 18,187 reported for the second quarter of 2025/26, the most recent period for which data is available (17).
Workforce challenges as an inhibitor of progress on IOAPs
The mental health sector is particularly badly affected by staffing shortages. In the quarter to the end of September 2025, the medical and nursing vacancy rates in mental health trusts were 10.5 per cent and 9.9 per cent respectively, compared to 3.8 per cent and 5.2 per cent in acute trusts (18). The Royal College of Psychiatrists’ latest biennial workforce census, relating to 2023, found that that 15.9 per cent of consultant psychiatrist posts were vacant across English NHS trusts, with ‘true vacancy’ rates of 29.1 per cent once locum posts were also factored in (19).
Participants in our roundtable discussions felt that workforce recruitment and retention issues presented an ongoing, serious barrier to improvement. Some services that are important for reducing delays to discharge were experiencing difficulties recruiting to specific posts, such as occupational therapists, to work in supported housing settings. We also heard that finite resources can inhibit potential improvements. Re-investing money saved through reducing IOAPs into roles that can improve efficiency, such as embedding more social workers into NHS settings, help prevent IOAPs in the long run (3).
The 2023 NHS Long Term Workforce Plan included stretching targets to expand the mental health workforce, acknowledging the increases in demand and unmet need that exists. With the development of a ten-year workforce plan for the NHS, it is important that it focuses on growing the skills and capacity to move care further upstream and providing services closer to home, particularly community-based mental health professionals, including non-clinical roles that may be employed by non-NHS organisations.
Responding to the challenge of IOAPs
The NHS 2025/26 operational planning guidance reflected that IOAPs are a challenge across the mental health pathway and with relevance to the wider health and care system.
The 2026/27 thee year NHS Medium Term Planning Framework states that all integrated care boards (ICBs) and mental health providers must reduce IOAPs by March 2027, and to continue to reduce or maintain IOAPs at zero by 2028/29 (20). From 2027/28, ICBs should only commission inpatient services that align with the NHS Commissioning Framework (21). £75 million of capital funding has been allocated in 2025/26 to assist systems and NHS provider collaboratives to work towards some or all of the following areas:
- Reducing IOAPs 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 in adult and CYP medium and low secure services (22).
To date, suggestions for how to solve the challenge of IOAPs have often included increasing capacity (15), enhancing the quality and quantity of information available about drivers of IOAPs, improving patient flow (23) and streamlining how care is organised via closer coordination between system partners (11). The complexity of the current challenge regarding IOAPs means that fundamental cross-system action building on these recommendations is needed to fully address the problem. To date, suggestions for how to solve the challenge of IOAPs have often included increasing capacity (Royal College of Psychiatrists, 2022b), enhancing the quality and quantity of information available about drivers of IOAPs, improving patient flow (Royal College of Psychiatrists, 2022a) and streamlining how care is organised via closer coordination between system partners (Armistead, 2024). The complexity of the current challenge regarding IOAPs means that to fully address the problem, fundamental cross-system action building on these recommendations is needed.
Leaders participating in our roundtable discussions felt the challenge of reducing IOAPs was inseparable from fundamental issues of capacity and flow. Avoiding admissions and facilitating efficient discharge, through improved access to community services pre- and post-discharge, can reduce pressure on acute capacity.
Patients are too often seen and treated at the point of crisis. They can remain in hospital when clinically able to leave because of a lack of community provision and clinicians not being confident in discharging patients due to this. Mental health patients are more than twice as likely to wait more than 12 hours in accident and emergency departments than all other patients combined (24). This has adverse consequences for those with mental illness who attend accident and emergency departments in crisis, but also for those attending urgent and emergency care for physical health issues, impacting bed and staffing capacity and increasing waiting times.
Leaders agreed that this poses a fundamental challenge to assumptions about the existing model of care in acute mental health, and that improved community provision could support reduced reliance on bed-based care. Even so, it was also accepted that community-based teams could not be expected to replicate every aspect of inpatient treatment. There will always be a proportion of patients who will need to be admitted to an inpatient unit, even if this should constitute a much smaller number than the current inpatient population.
Several leaders cited how their health systems are trying to move away from bed-based care by enhancing community provision to support patients before they needed an admission, and to help patients leave acute settings earlier in a safe and supported way. Examples of this work are outlined later in this report, in the section titled Positive Change Within the Mental Health Provider Sector.
Further, roundtable participants stated that some role types, such as peer support workers, neighbourhood co-production teams and paediatric liaison psychiatrists, could make an impact on preventing admissions and reducing length of stay. Significantly, people in these roles often focus on relationship-building and continuity as part of their work – these were principles that multiple participants felt were key to unlocking improvements in reducing IOAPs. For example, community support workers can help to build wellbeing by encouraging people to be active, in work or volunteering, with a stable home and income.
The role of capital funding in reducing IOAPs
Lord Darzi’s independent investigation into the NHS makes a direct link between the lack of sufficient good quality facilities and mental health inpatients being accommodated far from home (25). Mental health providers need greater capital funding to improve care facilities and reduce IOAPs, as well as reducing the subsequent revenue cost. The NHS Confederation has argued that increased capital funding, for both mental health providers and across the sector more widely, is essential to improving productivity (26) and that private investment routes should be used to deliver this (27).
Within available capital funding, greater allocative efficiency could be achieved by giving mental health providers the resources to increase their capacity. In turn, this would reduce pressure on acute providers by reducing the number of patients admitted to accident and emergency departments and general hospital wards with acute mental health conditions. While £120 million of capital for 50 new mental health emergency departments (units co-located with acute hospital accident and emergency departments) committed to by the government may help to improve crisis provision in some locations, this will not be a model that works for every geography and patient.
Additional capital spending in the mental health sector could increase provision of supported housing to improve flow and reduce length of stay. In those areas where under-provision of beds is still a challenge, capital investment is necessary to expand capacity to ensure adequate provision is available. To better understand the scale of the problem, local areas should be supported through national guidance to assess local bed capacity, with a focus on strategic commissioning to ensure bed distribution matches local need and appropriate models of care for the population.
Clarifying the role of the independent sector
The independent sector plays a significant role in the provision of inpatient mental health services (28), reducing overall numbers of IOAPs and providing additional places at a distance where needed. Independent sector providers can be commissioned via block contracts to provide capacity as part of the ‘usual network of care’ in an area. In circumstances where insufficient capital funding is available, commissioning independent sector beds are an important way to meet demand. When there are no beds available locally, systems often turn to independent providers out of area to spot purchase beds as IOAPs.
At present, independent sector beds procured as part of a usual network of care (through a block contract) are not considered to be an inappropriate adult OAP, as it is part of the natural clinical flow. For spot-purchased beds, NHS England has confirmed that if the bed is within the system catchment area and the IS provider is delivering on continuity of care via visits from the patient’s care co-ordinator and effective discharge planning, this would not be classed as IOAP. Sending providers retain responsibility for determining whether a placement is classed as an adult acute IOAP.
However, there is a lack of consistency and understanding within the sector on how these definitions are applied.
Revising and clarifying the overarching definition of IOAP definitions, for instance so that these relate purely to distance travelled, would simplify the process, more accurately reflect capacity challenges, and increase flexibility without negatively affecting patients.
Maximising the potential of prevention and community provision
Strengthening the role of provider organisations working within the prevention and community components of the mental health pathway is crucial for improving continuity of care and reducing the number of avoidable admissions. Community mental health services can shorten length of stay by enabling patients to be discharged more quickly.
The Community Mental Health Framework (CMHF) was developed by the National Collaborating Centre for Mental Health (NCCMH) within the Royal College of Psychiatrists. The framework promotes an approach in which people with mental health problems are active participants in making positive changes, rather than passive recipients of disjointed, inconsistent and episodic care. While there has been progress in the implementation of the framework, it is patchy across the country (29).
Implementing the framework was intended to deliver:
- more effective allocation of resources
- improved integration of services
- better support for the primary care workforce
- development of people’s personal skills, as well as building of resources and available assets
- access to support, care and treatment that meets people’s needs within their communities and across all organisations and sectors.
The framework encourages using all available community assets, such as libraries, leisure and social activities, and faith groups, to support those with severe mental illness. However, the focus has been more on those patients who ‘fall through the gap’ between primary and secondary care. Given inherently finite resources this has resulted in a reduction of resources originally earmarked for community mental health teams (CMHTs).
Community mental health teams can intervene earlier to prevent worsening symptoms, including by addressing wider determinants of health by signposting to benefits advice, housing support and food bank provision, helping to avoid admissions pre- and post-inpatient stay.
There has some inconsistency in the implementation of the CMHF, but in places where the model has been implemented well, there have been significant improvements in access, experience and outcome for people with mental illness. For example, Tees, Esk and Wear Valleys and Somerset. Six pilot, 24/7 local neighbourhood centres are testing an enhanced version of the CMHF model, offering round-the-clock local neighbourhood centres, providing healthcare, housing and employment support to address serious mental illness. They aim to reduce waiting times by using an open access model and the 10 Year Health Plan commits to expansion of these models. (30). This place-based community mental health model with whole-person, whole-population health approaches, aligned with primary care networks (31), can prevent worsening ill health, relieve pressure on inpatient beds and put the NHS on a more financially sustainable footing.
For children and young people, mental health support teams are being established in schools (32) along with community-based early access hubs (33), to enable early intervention when a child or young person has a mental health need.
Recognising the importance of good communication and information provision
A clear thread running through both the working age adults’ and children and young people’s roundtables was the importance of strengthening relationships as a route to reducing and ultimately eliminating IOAPs.
Relevant relationships include those between the patient (and their family/carers where appropriate) and professionals such as care coordinators; staff providing care with the aim of preventing admissions and rehabilitating post-discharge; local authority teams and staff in the IOAP provider organisation. Strengthening relationships between patients and professionals responsible for providing their care at different stages of the journey can lessen the negative impact of an IOAP, as well as avoiding admissions and speeding up discharge. Health and care staff taking the time to listen to what matters most to patients is an important part of this.
Enhancing information sharing between health and care professionals in the NHS, independent, voluntary sectors and local authorities at different stages of the patient journey can also help optimise the amount of time an individual patient spends in an inpatient facility. This is particularly important when a patient is being treated at a distance and staff at the inpatient unit and within the community that the patient will return to need to be able to access information about the patient’s progress. This is also important for children and young people, with health, social care and education services all involved. Some trusts are using an assertive case management approach to support this goal, assigning each patient sent out of area with a designated care coordinator who is specifically tasked with ensuring relationships are maintained between the patient and their family and their home mental health services.
Information sharing is also relevant to good patient care. A study with adolescent patients and carers has proposed that for those patients in, or about to go into, an IOAP, providing easily accessible practical information about the location and routines of the unit, including pictures and information about visiting, can help alleviate fears and concerns. Patients participating in the research welcomed easily available online information covering these points. Offering an element of choice can be helpful if feasible, as can providing clearer information to families about available financial and other support (1).
Access to better data on the nature of demand for inpatient mental health services across a health system can improve flow across a pathway. Within an individual provider, stronger connections between professionals as part of multi-disciplinary team working and as part of service design discussions can improve efficiency and reducing unnecessary admissions.
Consistent messages from senior managers and clinical leaders emphasising improved patient outcomes and experience can help IOAP reduction initiatives across organisations and encourage clinicians to move away from an overly risk-averse approach when considering whether or not to admit a patient.
Maintaining progress in the context of NHS reform
The 10 Year Health Plan can be an opportunity to tackle IOAPs if well implemented and fully funded over the decade. Moving care from hospitals to communities, making better use of technology and focusing on preventing sickness, not just treating it, should help to reduce both adult and CYP IOAPs (34).
Reducing IOAPs is an important way for the NHS to save money and improve productivity in the context of ambitious sectoral cost improvement programmes. There are already strong incentives in place to discourage IOAPs, not least because of their impact on patients, but alignment of wider incentives – including targets, oversights and financial flows – is needed to help providers deliver the shifts and reduce IOAPs.
Any review of performance management targets and metrics should consider whether the current approach to defining and recording IOAPs could be improved, in particular the treatment of geographically close spot-purchased independent sector beds as IOAPs.
A shift in emphasis away from central management of the NHS led by NHS England and towards regions and systems should ensure mental health service configuration is more directly informed by local need and by the specific characteristics of service providers. However, any reform programme risks delays in the delivery of improvements while high-level changes take place. It is important not to distract attention away from efforts to reduce IOAPs. Integrated care systems (ICSs) and the DHSC must ensure mental health provider organisations continue to be supported to reduce them, given the severity of their impact on patients, families, carers and health systems.
Positive change within the mental health provider sector
Despite the challenges described above, mental health organisations are already delivering positive changes that are helping to reduce the prevalence and impact of IOAPs. The next section of this report highlights positive practice examples from providers of NHS mental health services across England.
Reducing unnecessary CYP admissions through a children’s home providing intensive support in Hertfordshire and West Essex
Hertfordshire County Council and Hertfordshire and West Essex ICB observed an unmanageable increase in admissions of children and young people with complex mental health needs. This resulted in many overly long and costly stays, including in A&E, acute wards and psychiatric inpatient units, with discharge delayed due to a lack of alternative provision.
The council and the ICB developed Cherry Tree Cottage (CTC), a specialist children’s home operated through an integrated health and social care staffing model. It offers a 12-week programme of support for up to four 12-to-17-year-olds who are at risk of repeat A&E attendance or admission to tier 4 provision. The home provides a bright and healthy environment for patients as they receive individual physical and mental health, social care and educative support.
CTC has resulted in a reduction in A&E presentations and acute admissions, earlier discharge of residents who had been inpatients, overall cost savings and improvements in wellbeing.
Reducing unnecessary CYP admissions with an intensive home treatment service in Tees Esk and Wear Valleys
Following the closure of an inpatient mental health unit due to the tragic deaths of three young people, Tees Esk and Wear Valleys Foundation Trust (TEWV) was concerned that many children and young people would be forced to out of the area if they needed admission as an inpatient.
As well as opening up ten beds on a closer site, TEWV explored how to provide more care outside of an inpatient setting. It developed a crisis resolution and home treatment team service (CRHT) to provide specialist triage, assessment and treatment for people aged over 16 years who need urgent mental health care. Intensive home treatment (IHT) involves daily face-to-face visits for the first three days, followed by a programme of visits and/or remote consultations tailored to suit the patient, with a daily review by a multidisciplinary team. The team also supports younger inpatients to return home more quickly by working with them on a detailed care plan that could include a period of intensive home treatment and provides a specialist eating disorder IHT to visit patients during mealtimes at home or in hospital.
TEWV now has the lowest level of admissions for children and young people in the north east and one of the lowest levels nationally. The CRHT approach has enabled fast triage of patients in crisis, meaning urgent referrals and follow-ups can usually be put in place within four hours.
Avoiding admission through an enhanced support suite in North Staffordshire
In the period since the COVID-19 pandemic, North Staffordshire Combined Healthcare Trust has experienced a significant increase in the acuity of children and young people presenting at its services. Some children and young people admitted to a general adolescent unit (GAU) were then being referred to a psychiatric intensive care unit (PICU), which was not believed to be beneficial for them, especially those where attachment trauma was part of their clinical formulation and which often involved out of area transfers and disruption to care continuity.
The trust developed and piloted an enhanced support suite within its GAU to remove the need for patients to step up to PICU if their condition worsens temporarily. The suite was designed with equipment and adaptations so it could be used dynamically depending on individual need, from being used for a short period of time to support a patient with regulation of high-intensity feeding, to being used as a bedroom for support over a longer period. GAU staff were provided with training to support these new duties, including positive behaviour support training and non-violent resistance training.
While performance data is not yet available, the theory of change expects that the avoidance of unnecessary PICU referrals, along with quicker returns to standard GAU care, should improve patient outcomes and reduce the number of patients having to access care far from their family and carers.
Watch the staff interviews about the project and a walkthrough visual of the facility.
Avoiding admissions and supporting timely discharge through a single front door and a range of crisis and community support services in Somerset
Somerset NHS Foundation Trust sought to reduce the number of people being treated outside the area and bring them back to Somerset.
The trust took a collaborative approach between local services, including through the Somerset Open Mental Health alliance, which includes NHS, local government and VCSE organisations, with Rethink Mental Illness acting as Lead Accountable Body (LAB). This model has enabled the NHS to contract with a wide range of small and micro-organisations, through the LAB taking responsibility for governance, data, risk and central coordination.
This collaboration has ensured there is no ‘wrong front door’ for people seeking care, and that eligibility criteria for one service will not prevent them from receiving appropriate support. The organisations work together as an integrated team, committed to ensuring each person is directed to the right place. Services that can be provided to support people in crisis and help avoid an admission include a 24/7 crisis safe space, a helpline, a first response and urgent treatment team, crisis beds, and an urgent care hub. As a result of the Open Mental Health programme, there has been a 16 per cent decrease in adult/older adult inpatient admissions and an 18 per cent decrease in mental health A&E attendances.
As a companion project to the ‘single front door’ approach, Somerset has developed a set of services to support early discharge of patients. This is to ensure there is a stepdown process after leaving inpatient care. This includes intensive home treatment, community mental health team support and Somerset Open Mental Health services. Again via Open Mental Health, support is provided for people in and around their local communities, with a lead accountable organisation managing local referrals for support. Along with strong collaboration from social care, this has minimised delays to discharge, enabling people to be supported out of hospital as soon as possible. The Open Mental Health alliance approach has also helped to support, build and sustain the smaller voluntary sector organisations in Somerset, helping to strengthen community services and community identity for residents.
Reducing IOAPs through better referral management, greater support for staff and more efficient use of local beds in the East of England
The East of England Provider Collaborative for mental health services wished to understand what was driving an increase in IOAPs for children and young people and to reduce their number.
By pulling all referrals into a central flow hub and analysing relevant operational data, the staff identified which areas of CYP service needed to be prioritised. Managers understood that local general adolescent unit (GAU) beds had been closed in recent years and that far fewer IOAPs would be needed for these priority patients if the closed GAU beds could be reopened. They learned that these beds had been closed due to workforce capacity issues and conducted engagement and training to understand why some staff were dealing with disproportionate levels of acuity and complexity and provide them with more support to manage their roles. Managers ensured more complex patients would be more evenly distributed across all available local services, making staffing more sustainable. They also used contractual levels to ensure all beds contracted for were being made available, maximising local capacity and minimising need for out-of-area beds.
These activities have reduced the number of CYP IOAP bed days by 42 per cent in two years. Local beds are used more efficiently, which has freed up fund that the collaborative have reinvested in a range of admissions avoidance services.
Improving patient flow through a red-to-green system and better managed inpatient care and discharge planning in Avon and Wiltshire
Avon and Wiltshire Partnership Trust conducted diagnostic and improvement activities to reduce and sustainably minimise its number of IOAPs.
To improve patient flow through the system, the trust adopted a red-to-green system in its care pathway programme. This involved clinical teams reviewing why each patient had been admitted, whether that purpose had been met or if they needed further treatment, deciding on an estimated date for discharge, and then following these up with actions for the team to complete.
The trust also improved planning for patients who were clinically ready to be discharged. The trust worked closely with partners including local authorities to check the quality of care packages and ensure that plans to reintroduce patients into the community were appropriate for their needs. This improved the success of community care pathways and made the process of discharge safer and more effective.
Together these approaches also helped improvements in the flow of patients, contributing to a significant reduction in IOAPs and financial savings
Driving more effective discharges and reducing re-admissions through step-down housing support
In 2015 the Oxfordshire Mental Health Partnership established the Response Littlemore Campus, an intensive supported housing service for people with complex mental health challenges.
it is part of a full pathway of support, ranging from 24/7 intensive care through to unstaffed houses with visiting support. Oxford Health NHS Foundation Trust is the lead contractor and subcontracts to Response and other voluntary sector providers.
The campus is based around a former hospital building gifted to Response by Oxford Health NHS FT, as well as another building rented from the trust and a street of houses owned by a housing association. The layout of the campus is similar to that of a traditional small housing development.
Placements are for two-to-five years but can be extended. There is an embedded clinical team that includes nurses and social workers, as well as having access to a consultant psychiatrist, occupational therapists and psychologists. There are close links to primary care and police.
Staff also provide in-reach into inpatient wards to help effective discharge planning, and after discharge work with patients to re-engage with the community, explore training and work opportunities, manage medications and develop independent living skills.
As a result of the service, inappropriate out of area placements and re-admissions after 90 days are consistently low.
Working with the independent sector to boost NHS inpatient capacity
In Preston, Lancashire, a new 12-bed acute ward for male patients has been commissioned from independent sector provider the Priory Group by the local trust. The £4.5 million ward was initially developed at Priory Group’s own financial risk. It offers round-the-clock support for people suffering a mental health crisis and has been consistently full with local patients since opening, preventing 85 IOAPs and reducing average length of stay to below the national average. Reducing length of stay alone has saved £250,000. It is one of four new wards for NHS patients that Priory Group opened in England in 2024, the others being in Birmingham, Nottingham and Cheadle Royal, Cheshire.
Recommendations
Despite efforts to reduce adult IOAPs over several years, they continue to endure. Meanwhile, inappropriate CYP OAPs have not received the same attention and also remain a significant problem. These placements have negative consequences for patients, families and carers as well as for the efficiency of health and social care systems. Previous recommendations around increasing capacity, streamlining care and enhancing communication between system partners remain valid, but the challenge around IOAP reduction is now so acute that more concerted action is needed to reduce them.
Delivering the three shifts outlined in the 10 Year Health Plan can reduce IOAPs by boosting the role of community provision, admission prevention approaches and improving data flows. However, major reforms to NHS infrastructure - including a reduction in ICB funding and organisational change through mergers and clustering, reductions in providers’ corporate spending and the abolition of NHS England - risk diverting attention at the expense of improving patient care. Recruitment and retention of appropriately skilled staff need to be a priority.
IOAPs are symptomatic of the wider challenges of improving flow and ensuring appropriate capacity within health systems. Decision-makers should avoid treating them as a standalone issue and instead create strategies that acknowledge their status as a symptom of systemic problems within and beyond the mental health pathway, including challenges to discharge.
Solutions are generally well understood – the challenge is implementing them at a time when funding is scarce and opportunities to invest in new buildings and facilities are extremely limited. Given these constraints, reducing restrictions on provider organisations and encouraging greater innovation and partnership working will be important, but this on its own is unlikely to be sufficient.
We propose six recommendations to national bodies, which will support the health and care system to reduce IOAPs.
We have also identified key learnings from existing innovation and good practice, for providers and commissioners to consider when developing their approach to reducing IOAPs.
National recommendations
- National guidance from NHS England is required to support systems to assess local bed capacity, including a focus on strategic commissioning to ensure bed distribution matches local need, reflecting projected and appropriate models of care for the population.
- The DHSC and NHS England should review current and projected mental health capital funding needs, with the objective of ensuring that mental health providers receive an appropriate proportion of available capital funding.
- Changes to capital funding rules outlined in the 10 Year Health Plan should be accelerated as a priority to make it easier for NHS organisations to generate new funds, and to use the receipts from sales of assets to invest in new and refurbished buildings committed to in the NHS 10 Year Health Plan.
- To improve flow and free up beds for those that need them, the DHSC and NHS England should assess the impact of previous targeted funding and the 2022 Discharge Challenge and consider whether similar mechanisms may help accelerate reduction in IOAPs and length of stay.
- DHSC and NHS England should work with systems, providers and people with lived experience to revise the overarching definition of IOAPs. The current inclusion that in-area placements are required to be ‘part of the usual local network of services’ can lead to unintended consequences, such as badging placements as ‘in-area’ when the patient is far from home, or treating local independent sector placements as IOAPs. A definition based on a judgement of how easy it is for a patient to keep connected to formal and informal support, such as their care-coordinators and families, would better reflect the interests of patients and capacity challenges. Existing and any new definitions must be consistently applied across all providers and systems and for both adult and children and young people’s services.
- The government should ensure that even in the face of funding pressures, appropriate levels of investment are in place to deliver new models of community-based care, crisis support, access to evidenced-based care pathways and preventative approaches envisaged in the 10 Year Health Plan.
Key learnings for providers and commissioners to consider
Demand reduction
- ‘No wrong front door’ policies help ensure patients are navigated to the right service, no matter how they try to access care, so that opportunities to intervene before admission are not missed.
- At the provider collaborative level, central referral hubs can help identify patients who might be better served by a service other than inpatient provision. This supports more efficient use of inpatient beds, as well as identifying areas that lack capacity. Models adopted for more specialist services, such as eating disorder services, to pool beds across a provider collaborative, can increase bed availability and improve continuity of care.
- For CYP services, approaches already in use in adult services should be explored, such as enhanced support suites designed to occupy the space between GAU and PICU, removing the need for patients to step up to PICU if their condition temporarily worsens.
Avoiding prolonged inpatient episodes
- ‘In-reach’ approaches for inpatients nearing the end of a hospital stay can be used by community mental health teams to establish relationships with patients, supporting them to live successfully in the community and reduce readmission rates.
- A network of stepdown services such as supported housing, intensive home treatment, social care provision, community mental health team support, and recovery-based offers via partner organisations, can help with effective early supportive discharge. particularly when coordinated effectively, and where data on impact is captured and learning built into the further development of services and partnerships.
- Providers can institute a more systematic programme of checks with local authorities as patients near the point of being ready to leave hospital to ensure that care packages and community-based arrangements for patients are in place, reducing the risk of delayed discharge.
- Red-to-green systems can improve patient flow and help ensure patients do not remain in hospital unnecessarily. They increase understanding of why patients have been admitted, consider whether the purpose of admission has been met or if further treatment is needed, estimate a date for discharge and increase accountability for actions needed to work towards discharge.
Pathway redevelopment
- Quality improvement methods are well suited to addressing complex multifactorial problems such as IOAPs. These methods can be helpful in planning projects and designing solutions to reduce IOAPs.
- Ensuring that clinicians play a leading role in the design and deployment of strategies and approaches to reduce IOAPs is vital, especially where these involve changes to the way care is provided. Emphasising improved patient outcomes and experience, rather than financial savings and targets, and supporting clinicians to step back from an overly risk-averse approach can help better engage clinicians in the process.
- Where changes are to be made to the way care is provided, patients and carers should be consulted and offered the opportunity to contribute meaningfully to new service designs and evaluations.
- The direction of travel is to support more people in the community. However, even as new models develop and impact bed requirements, strategic conversations with independent sector providers at system and provider collaborative level will help ensure the most efficient use of NHS funds, particularly where NHS capital funding is inadequate and mental health facilities require upgrading.
- Build in economic evaluation from the beginning of any pathway redevelopment. While this can be difficult due to multiple variables impacting on IOAPs, being able to evidence financial savings and return on investment is vital to make the case to invest or continue to fund new approaches.
Quality assurance for unavoidable OAPs
- Where an IOAP is unavoidable, efforts should be made to ensure that patients and families are as prepared and supported as possible. This can include sharing information about the hospital the patient will be travelling to, such as a description or video walk-through of the ward and an outline of the routines and activities. Discussions about whether some areas would be more suitable than others can also help reduce the negative impact of IOAPs.
- Regular reviews of the IOAP status, and proactive contact between patients who are sent out of area and their sender organisation, can help determine whether a transfer to a bed nearer home is possible and help patients feel they have not been ‘forgotten’.
Conclusion
Despite the efforts of the mental health sector, rising demand on services, levels of increased acuity in patients, workforce challenges and finite resources have meant a steady increase in IOAPs since the pandemic. The financial cost reported of £164 million in 2023/24 is likely to be much higher, due to issues with data reporting. The negative and long-term impacts on patients and loved ones who have experienced an IOAP cannot be quantified but can include significant impact on education and employment.
IOAPs are a symptom of pressure across the mental health pathway and wider system and therefore require a system response. It is not just down to statutory mental health providers. This project has shown that wider partnership working plays a vital role.
There are opportunities in the implementation of the 10 Year Health Plan to provide more proactive care, based on the principles of prevention and community, through the 24/7 mental health neighbourhood pilots, assertive outreach teams and mental health emergency departments.
We will continue to gather and share good practice from approaches the sector is taking to reduce out of area placement and provide better care, closer to home.
We would like to thank Dominic Hardisty, chief executive of Avon and Wiltshire Partnership NHS Trust and Dr Trudi Seneviratne OBE, immediate past registrar of the Royal College of Psychiatrists and consultant adult and perinatal psychiatrist, and all the individuals who provided invaluable input into the report.
