In the West Midlands, Birmingham and Solihull Mental Health NHS Foundation Trust, Midlands Partnership Foundation Trust, St Andrew's Healthcare and Coventry and Warwickshire Partnership Foundation Trust are working together through the Reach Out Provider Collaborative to improve adult secure care services.
The collaborative was part of the first wave of "new care models" selected by NHS England following the Five Year Forward View for Mental Health, published in 2016. In line with that publication's recommendation to allow providers to manage budgets of specialised services, the collaborative set out to improve the delivery of secure mental health care services across the region. Over time the collaborative expanded in 2021 to include secure inpatient learning disability and autism services.
From October 2021, NHS England began commissioning adult secure care services through a lead provider model. Under these arrangements, one trust holds a long-term contract covering a wide range of services, which it can then provide itself, or subcontract to other providers. In effect this transfers much of the responsibility for arranging and transforming services to the collaborative. On behalf of the Reach Out Provider Collaborative, Birmingham and Solihull NHS Foundation Trust took on the lead provider role. Under this arrangement, there is a robust decision-forming and decision-taking framework across the collaborative through strategic and professional input from the partners. The final decision taking sits within the lead provider commissioning committee, supported by the collaborative's executive team.
By working together and at scale, the collaborative has sought to improve secure services by providing them closer to home and in the least restrictive settings possible. Since implementing its new care model in 2017, the collaborative has made significant improvements to the care of people requiring access to services at low and medium secure care inpatient levels. This has been brought about by:
- a shared ambition to improve adult secure care for people in the West Midlands;
- improved clinical collaboration across the three partners;
- a focused case management team to review quality and focus on pathway facilitation on those in- and out-of-area;
- increased understanding of the needs of patients, and monitoring whether these needs are being met;
- improved data and analytics to understand pressures, trends, opportunities and potential problems.
The partners have also shared a key focus on quality, with a number of quality initiatives being recognised as national exemplars, and clinical innovation – such as co-producing an innovative 'blended' model to support women transitioning between medium and low secure services.
The collaborative has developed and embedded a robust co-production approach and infrastructure for working with experts-by-experience. All transformation workstreams have people with 'lived experience' involved to drive change by bringing their voice and supporting clinicians to improve how services are delivered. These activities are helped through training and support to enable true coproduction and design, and by a reward and recognition policy to compensate for people's time and input.
By working together since March 2017, the collaborative has made progress in reducing:
- mental health inpatient population by 11% (536 down to 479), and learning disability and autism (LDA) inpatient population by 60% (162 down to 64) by December 2024; and
- mental health out-of-area population by 54% (166 down to 76), and LDA out-of-area population by 73% (91 down to 25) by December 2024.
The collaborative refocused its care model which enabled a much more efficient use of resources, by reducing out of area placements, cutting length of stay and readmissions, and accelerating discharges into the community. The reduction in out of area mental health inpatient population resulted in significant savings which have been re-invested into community forensic mental health teams (FIRST).
The FIRST team provides intensive support for patients transitioning from a secure setting into the community by bringing together a multi-disciplinary team of consultant psychiatrists, advanced nurse practitioners, community psychiatric nurses, occupational therapists, support workers, peer support workers and social workers. These professionals can then offer each patient a tailored and holistic package of support. This approach empowers patients by involving the individual, their family and carers in all stages of care planning. The peer support workers, who are former service users, support current patients through their recovery and stepping down into community. Secondary care and criminal justice services are provided alongside support workers and social workers – as well as case managers who ensure alternatives to admission are appropriately considered. This ensures a continual focus on community-based interventions.
The success of this model and the return on investment can be evidenced by growth in numbers of patients supported in the community from 110 in 2017 to 230 in December 2024; 108% growth. And these numbers don’t represent the patients who are further stepped down from community forensic support into non-secure pathways.
The collaborative has also heavily invested in health inequalities, physical health, environment, transport and digital health to improve access, experience and outcomes of patients. They have recently approved a two-year pilot programme to introduce a community rehabilitation service to support timely discharge from women’s inpatient services. This pilot aims to improve service user experience and reduce overall costs by reducing length of stay.
The collaborative is now working closely with the six ICBs and providing non-recurrent funding into non-secure community pathways to support seamless stepdown between services and ensuring care in the least restrictive setting possible. This will be achieved through building capacity and capability both within the secure and non-secure community services through liaison schemes and developing relationships and mutual processes.