Placing social workers in mental health trusts can help tackle out-of-area placements, says report

Integrating local authority social workers within NHS mental health trusts can help reduce the number of “harmful” out-of-area hospital placements (OAPs), a report has found.

The Health Services Safety Investigations Body (HSSIB) said that placing social workers in mental health hospitals could help speed up safe discharge, thereby freeing up beds and enabling discharge.

However, the report said that, in recent years, councils had withdrawn social workers from integrated services hosted by NHS mental health trusts, despite such arrangements being seen as beneficial by practitioners.

The HSSIB investigates patient safety concerns across the NHS in England. Its study of OAPs was part of a wider government-commissioned investigation into the safety of mental health inpatient setting, with previous reports covering the assessment of suicide risk and safety planning and the impact of workforce challenges on the delivery of safe and therapeutic care.

Missed target to eliminate inappropriate out-of-area placements

Under government guidance, an OAP occurs when a person is placed in an inpatient unit that does not usually admit people from their area and where they cannot be visited regularly by their care co-ordinator.

In 2016, the then government set a target of eliminating inappropriate OAPs – meaning those where the person was placed out of area because no acute mental health beds was available locally – by 2020-21.

However, this target was missed and, as of 31 March 2024, there were 900 out-of-area placements in England, of which 805 were inappropriate, based on data from 72% of relevant organisations.

NHS England told the HSSIB that increased complexity of need in the wake of the pandemic had had an impact on treatment times and lengths of stay in hospital that had not been planned for, leading to increased use of out-of-area placements.

Harm from being placed out of area

The HSSIB found that people and their families and carers were being harmed by OAPs, due to the increased anxiety of not knowing new staff and being separated from support networks.

The placements were also resulting in “significant anger, frustration and loss of trust in the mental health system”.

However, many NHS trusts told investigators they were “overwhelmed” by the number of people needing acute care and felt they did not have any option but to use OAPs, as this was better than the person remaining unwell in the community.

NHS England has put forward using community mental health, crisis and home treatment teams as key to tackling OAPs, by reducing people’s need for inpatient care.

But trusts said that there was “not always have the time, capacity or ability to make the changes needed” because of the pressure they were under.

Mental health system ‘cannot be looked at in isolation’

Practitioners told the HSSIB that the mental health system could not be looked at in isolation in consider OAPs.

“Many patients needed acute services because the lack of appropriate provision of community mental health care, social care support, drug and alcohol services, or delayed diagnosis of neurodevelopmental conditions, meant their needs had not been met to keep them safe in the community,” the report said.

The investigation found that “limited patient flow through mental health and other services”, meant it was difficult for trusts to discharge people from hospital, with the resulting lack of beds driving OAPs.

Local authority social workers told the HSSIB that high caseloads and “too many competing priorities” meant that they struggled to support the timely discharge of people from mental health wards, while the process was also slowed down by struggles getting support packages signed off by funding panels.

Loss of social workers from integrated teams

Practitioners told investigators that patients had benefited from council social workers being integrated into mental health trusts through partnership agreements drawn up under section 75 of the NHS Act 2006.

Social workers said this had given them greater visibility of patients in hospital and in the community and promoted collaborative working and improved understanding of cross-system pressures.

However, councils have pulled out of section 75 agreements in many areas over the past several years, reportedly due to operational pressures in other parts of the social work system, said the HSSIB.

This had had the unintended consequence of social workers who lacked mental health experience being assigned to support a patient.

Call to embed social workers in mental health hospitals

Based on its findings, the HSSIB said: “Health and social care organisations can improve patient safety by working together and embedding mental health social workers from the local authority in mental health acute hospitals.

“This can ensure that patients’ holistic health and social care needs are considered throughout their acute mental health admission and on into the community, and improve efficiency of working, patient flow and discharge and reduce the use of out-of-area placements.”

It recommended that the Department of Health and Social Care (DHSC) reviews current policies concerning mental health, social care and housing impacting on OAPs and “creates a proposal for the future accountability and integration of health and social care”, to help reduce and prevent out-of-area placements.

‘Close working relationships should be the norm’ – BASW

In response to the findings, British Association of Social Workers chief executive Ruth Allen, a former mental health social work director, said: “Section 75 arrangements have had challenges for the governance and quality of social care and social work when staff are seconded to Trusts.

“They have also foundered because of financial pressures.  But the principle of joint working on the ground and seamless, holistic support must not be lost in high level debates and disagreements about money and accountability.”

She added: “Joint teams and close working relationships should be the norm, and social workers must be available to support social needs and issues – in whatever way they are employed and managed.

“A focus on high quality delivery arrangements in well-functioning multidisciplinary teams – rather than on particular structures of multiagency governance and contracting – may break down barriers between professionals more effectively and ensure more truly integrated practice.”

In its response to the report, the DHSC said: “Patient safety is paramount, and anyone receiving treatment in an inpatient mental health facility deserves safe, high-quality care, and to be treated with dignity and respect…This government will reform the Mental Health Act, to ensure that people with the most severe mental health conditions receive better, more personalised treatment that is appropriate, proportionate, and compassionate to their needs.”