A mental health project is improving outcomes for patients by enabling them to be cared for closer to home, as well as saving millions of pounds for the clinical commissioning groups involved. By Sally Eason.
For Pam, the agony of having her husband, Ken, move into a care home because of his advancing dementia was magnified when he was moved to Northampton – many miles from their home in the West Midlands.
Being so far away meant it was more difficult for Pam to go and see Ken regularly, and added to her stress levels.
But then a mental health repatriation project, run by NHS Arden & GEM Commissioning Support Unit (CSU) in partnership with Coventry and Warwickshire Partnership NHS Trust (CWPT), stepped in and enabled Ken to move to a care home just 10 miles from Pam.
“I think it’s a fantastic idea,” says Pam. “Keith gets to see me far more, we get better time together and it’s so much less stressful for me.”
This is one example of how NHS Arden & GEM Commissioning CSU and CWPT’s repatriation project has improved patient outcomes. But this is not the only advantage it brings: it is also responsible for cost savings and improvements in local care provision.
To date, the Mental Health Repatriation project has delivered cost savings in excess of £12 million for the three clinical commissioning groups (CCGs) involved – NHS Coventry and Rugby CCG, NHS South Warwickshire CCG and NHS Warwickshire North CCG. Having focused initially on adults with mental health needs, the project has since been expanded to take in those with learning disabilities and dementia.
Understanding the challenge
The project came about after analysis of mental health spend across Coventry and Warwickshire in 2011 found that less than 50% of the budget was being spent on local services. Many patients were being treated in specialist centres out-of-area, sometimes hundreds of miles away from friends and family. This scenario had come about due to a limited number of local places to support complex patients with higher levels of need.
Further assessment showed that patient outcomes could be improved if they were treated closer to home, while costs could be reduced and more carefully managed through contracts with local providers. This heralded the start of the Mental Health Repatriation project which is now in its fifth year.
Developing a solution
Many of the patients potentially eligible for review under the Mental Health Repatriation scheme have complex care needs and any changes needed to be made with the support of the patient, their family and the professionals involved in their care. This required close collaboration between commissioners, local authorities and the mental health trust.
Working together, a whole system review was conducted, covering everything from clinical governance, training and contract management to quality assurance and performance monitoring to make the repatriation project work.
From the outset of the project, detailed work has gone into developing a comprehensive and transparent repatriation framework to monitor, track and minute every step of the clinical review process, ensuring patients, their families and care providers fully understand the review being undertaken.
To perform the detailed clinically-led reviews required, an experienced team was recruited from mental health nursing and occupational therapy backgrounds with an emphasis on assessment skills. Initially a team of five, specialist dementia and learning disability nurses as well as social care experts have subsequently been recruited, which has seen the team grow to 11 as the scope of the project has expanded.
The team’s principal focus is on delivering patient-centred care. As such, it is recognised that repatriation isn’t appropriate for everyone, particularly if they have already become settled in their local community and do not want to move. When a review indicates that remaining in an out-of-area specialist provision is in the best interests of the patient, the clinical review team advocates this.
In the first year, which focused exclusively on adults with mental health needs, 400 out-of-area patients were identified and by March 2014, 134 had moved.
About 100 people have been repatriated, while others have had their care packages adjusted to ensure their current care needs are being met. Many people have been able to step down to a less intense service.
Many patients are now benefiting from being closer to friends and family, with additional support provided according to their needs, including help to enable them to become part of their local community.
For instance, Michael has been able to return to his home town and now lives in a residential care home. He also enjoys regular contact with his family. “I can have a cup of tea round my Nan’s – that’s the best bit about it,” he says.
Another patient, Craig, is “over the moon” to be back in his local area, having previously been based in the East Midlands. He has his own flat and is learning basic living skills. “I love it here… I’m finally getting back to normality,” he says.
Another indicator of the success of the project is that the relapse rate of repatriated patients is currently less than 3%.
Better services, lower costs
As well as delivering better outcomes for service users, the project also brings substantial cost savings. Every year the project has delivered cost savings ahead of targets, with £12 million delivered to date. In addition, the project has avoided new costs by scrutinising plans to use out-of-area providers, and ensuring best use is made of local providers.
The increase in specialist beds and services locally means fewer people are placed out-of-area. When placing someone in an out-of-area setting is still felt to be necessary, there is a clear process in place that identifies when and how that person could be brought back.
One of the key elements that has allowed this project to be successful is the progressive attitude of the commissioners and mental health service provider.
This project operates across three CCGs and each one has different demographic profiles and pressures. Thanks to a desire across the patch to keep patients at the heart of the project, it has been possible to adopt a region-wide approach, avoiding the scheme becoming a postcode lottery. Rather than patients being repatriated based on allocating an even spread of savings, they are progressed through the system based on clinical need. All partners have embraced the wider benefit of this approach, rather than being constrained by funding splits, and recognise they may achieve more cost savings in their patch in one year than another.
Since April 2015, the Mental Health Repatriation project has been adopted as a self-funding, substantive service across Coventry and Warwickshire, enabling the region’s CCGs and local authorities to work together to care for patients with mental health needs within their own boundaries, wherever possible. As a result, some of the area’s most vulnerable people have been reengaged, with bespoke packages of care, enabling local commissioners to raise the status and responsiveness of mental health care.
About the author
Sally Eason is transformation partner at NHS Arden & GEM Commissioning Support Unit.
About NHS Arden & GEM Commissioning Support Unit
NHS Arden & GEM CSU provides commissioning support services including service transformation, informatics and continuing healthcare, as well as corporate functions such as finance and human resources. For more details, visit www.ardengemcsu.nhs.uk