South West Yorkshire Partnership (SWYPFT) since FY16/17 had long been using a significant number of out of area (OOA) acute and PICU beds.   This represented poor quality for those affected service users dislocated from local care networks.   The additional cost of these beds was £3-4m per annum.

Commissioners wanted to jointly agree an OOA reduction plan to achieve a Trust trajectory to zero by April-21. The VOT team were engaged late 2018 to guide plan formation. A hypothesis-led approach was taken to identify, work up and model the highest impact service changes.  By combining rigorous analytics with process observation and staff interview some powerful insights were discovered including:

• Recognition that bed moves including repatriations, although well intended, significantly extended overall length of stay
• OOA peaks arose after senior decision maker absence on the wards
• OOA growth coincided with a period of sharp referral growth per 100k population, but one locality absorbed referral pressure without experiencing bed overspill
• GP behaviour varied significantly inappropriate referrals for many were over 50%
• Clinicians weighed down by demand were questioning “who can we save, without spreading ourselves too thinly?..no is very difficult”.   There was a demand to clarify what we don’t do, specifically: accommodation; welfare; and substance misuse

Working with clinical and operational leads an OOA bed cessation programme was launched to deliver focused bottom-up service changes. Simultaneously the executive team set about the task of formalising a ‘low admission care closer to home’ model to bring improved clarity to teams in the acute pathway across the Trust.

The key cessation programme workstreams were:

1. Bed flow management – a centralised function or ‘brain’ to co-ordinate and minimise OOA bed usage. This meant doing basics well such as MDTs happening as scheduled to agreed start/finish so quorate for maximum impact; and effective leave planning/handovers.  It also requires real time bed visibility
2. Gatekeeping and fidelity – this meant, for example, ceasing referrals of community ‘non-admission risk’ cases to Home Treatment (HT); & a focus on ensuring HT attended all crisis assessments face-to-face in-hours
3. Community caseload – decompressing the community team caseloads was essential to support both HT to achieve fidelity and likewise single point of access (SPA) to assess and triage new referrals.  This meant clarifying a core/enhanced community team model offer and working through and codifying practice change adoption to free senior time to be more responsive
4. Primary care ‘1 in 10’ and triage – commissioners responded to the high level of inappropriate referrals by systemising place-based triage decision trees to facilitate effective referral and signposting of first time patient wellbeing needs. This was built into GP SystemOne software, which also facilitate appropriate Trust e-referrals. The Trust simultaneously focused on delivering early interventions at the first point of contact.

OOA usage fell consistently as initiatives achieved traction, by Sept-19 the figure was near zero and remained at similar levels as at the date of this case study. 

In cost terms the annualised saving is £3m+ at current levels.  The in-year saving has helped the Trust return to monthly surplus.  In the same period the Trust’s CQC rating rose to ‘good’ from ‘requires improvement’.