1. Policy Statement
Hull City Council will only place people in residential or nursing based services, or support health colleagues to place people in hospital settings which are located outside the Hull City Council boundaries, when either:
- There is clear, demonstrable evidence that their needs cannot be met by services located within the city;
- Where a time limited, therapeutic placement will deliver benefits which outweigh the negative effects of moving away from everyone and everything the person knows;
- They have made an informed, capacitated choice to move;
- They lack mental capacity but a formal best interest decision has been made that they would benefit from such a move (for example to be closer to family and friends);
- They have made a request to move to live near relatives or family;
- A decision has been made via the Multi Agency Public Protection Approach (MAPPA) that a person who has been the victim of neglect, abuse or other criminal offence needs an out of area placement as part of their protection plan.
When a person chooses to move out of the area, or a formal Best Interest decision has been made, supported by evidence that they would benefit from such a move then this can take place. However, this should be supported by robust monitoring and review as outlined below.
If there is a proposal to place someone permanently outside the City boundaries or across national borders i.e. in Scotland, Wales or Northern Ireland full consideration must be given during the planning process to the support networks the person may have in their local community and those which may exist in the area of the proposed move. The foreseeable effect of these support networks or their removal on the person’s wellbeing must be identified and taken fully into account.
If the person accesses any specialist healthcare in their current placement, full consideration must be given to how they will access this or similar in the locality of their proposed move.
If the person has requested a move to a different area or across a national border in order to be closer to family or friends, the views of these friends or family members must be sought during the planning stage.
The views of the person must be taken fully into account during the planning stage and their agreement achieved. If they lack mental capacity, an advocate should be appointed to represent their views.
When people are placed temporarily outside the city, planning to enable them to return to their local community should begin on day one of their placement and the monitoring of that placement should take account of the potential difficulties and additional risks caused by geographical distance from their community.
The City Council can take resources into account when agreeing a service response, including negotiating any out of area fees over acceptable levels of increase, currently set at two percent. Once the Council has assessed a person’s needs it has a duty to ensure services are provided to meet those needs whether in or out of area.
Hull City Council will contribute to the host authority’s ‘usual cost of care’. Rates will be subject to an annual review and the host authority must provide written information setting out any proposed increase.
In December 2012, the Department of Health published Transforming Care: A national response to Winterbourne View Hospital which drew attention to the additional difficulties experienced by many people living in out of area residential or hospital settings. The report states:
Sending people out of area can cause real harm…there should always be clear and compelling reasons for sending any individual out of area.
This policy will clarify the conditions under which an out of area placement can be made and the planning and monitoring process which must follow it including placements made across borders, i.e. in Scotland, Wales or Northern Ireland.
When people need specialist support, the default position should be to put this support into the person’s own home, including crisis support. (Transforming Care, Department of Health, 2012)
Statistically speaking, most out of area or cross border placements which have not been led by the person occur either as a consequence of a crisis or because a person has specific needs which local providers cannot meet. Prior to an out of area placement being considered, every effort must be made to support the person within their local community. This could include stimulating the local market to develop new and innovative services, imaginative use of a personal budget taken as a direct payment, short term high intensity support or holistic planning to address specific issues or resolve crisis which is person centred, led by specialists and contributed to by the person, their family and all agencies involved in the person’s care to ensure consistency. The learning and development needs of staff and family members should be considered and met to make sure the person has the right support to stay at home and any necessary equipment or adaptations should be sought. The cost of providing these inputs will usually be far less than the cost of providing a specialist placement out of area.
4. Making a Placement Out of Area
When someone is admitted to hospital (or otherwise placed out of area) the priority from the start should be rehabilitation and returning home. (Transforming Care, Department of Health, 2012)
If a person has requested an out of area or cross border placement for example to move closer to family, friends or other support networks or where it is likely that the admission to residential care will be permanent and that permanent admission to a particular home is demonstrably in the person’s best interests, that placement can be made by following the same procedure used for placements within the Hull City Council area, but with robust monitoring and review as set out below.
However, if the person wishes to stay within the City, but after every effort has been made to support them to stay at home, there is clear evidence that their needs can only be met by a service located out of area, then specific approval for that placement must be sought from the Assistant Head of Service for Vulnerable People. The placement should be time-limited, not open ended and should be made on the basis of a clear plan for treatment, rehabilitation, reablement or crisis resolution with the outcome of the person returning home. The views of the person and their family must be sought and regarded within the decision making process. A clear written plan should be produced which specifies the desired outcomes of the placement, the milestones towards achievement of those outcomes, agreed inputs and a timescale.
If agreement to the placement is achieved, Hull City Council must contact the local authority in whose area the placement is being made to notify them of their intention and the date of the proposed placement. They should provide the host authority with details of the proposed provider and seek their views as to the suitability of the proposed placement. This can be done initially by telephone but should be confirmed in writing.
If the person is to receive NHS funded nursing care as part of the placement, the Integrated Care Board (ICB) and the NHS body delivering the care must agree the placement prior to it being made. If a need for nursing care arises subsequently, the agreement of the ICB is not legally required, but it is good practice to make every effort to obtain it. Discussions must take place with them as they will be responsible for funding the nursing care element of any out of area or cross border placement.
Discussions should also take place with the host authority about any assistance Hull City Council may seek with regard to the ongoing management of the placement. Some responsibilities (for example the duty to review) cannot be delegated, but Hull City Council may wish to seek assistance with some of the day to day practicalities of managing the placement, for example initial crisis response or gathering information.
When the placement is confirmed, Hull City Council should notify the host authority of this in writing, detailing any agreements which have been made regarding day to day support to be given by the host authority, who should acknowledge receipt of this, also in writing.
5. Deprivation of Liberty
If it seems likely that someone placed out of area may need to be subject to Deprivation of Liberty, it is the responsibility of the placing authority to make and monitor the order. As with all such orders, it should seek to place the least amount of restriction on a person and should be for the shortest possible time and should be fully documented. See Deprivation of Liberty Safeguards.
6. Monitoring an Out of Area Placement
Reviews should focus on people’s views and experiences, on quality of service and on outcomes and not on containment or management of the original problem. (Transforming Care, Department of Health, 2012)
Monitoring and reviewing an out of area placement presents specific challenges caused by geographical distance and these functions cannot be delegated, although the assistance of the host authority can be made use of in discharging these duties. This, together with the isolation from family, friends and other support networks can make someone more vulnerable to abuse and can place them at greater risk of poor service, exploitation or abuse not being identified and addressed. This makes close monitoring of out of area placements more important than ever. Full use should be made of all monitoring tools available including electronic and social media, telephone contact with the person, actively seeking the views of friends and family and the use of advocates or peer advocates in the area local to the placement. Monitoring and review should focus on the views and experience of the person and their family, on quality of service and on progress towards the outcomes stated in the placement plan. If abuse is suspected to have occurred, a referral should be made to the safeguarding team in the area local to the placement and the outcome should be monitored.
7. Current Out of Area Placements
Anyone currently in an out of area placement must have their needs, care and support plan and service reviewed as soon as possible with the focus as stated above. Unless it is demonstrably in the person’s best interest to remain permanently where they are, a clear written plan should be produced which specifies the desired outcomes of the placement, the milestones towards achievement of those outcomes, agreed inputs and a timescale to return home. People should not remain in out of area placements simply because it would be challenging to facilitate their return and support them locally.
8. Links with Commissioning
If there are people currently in out of area placements or at risk of having to move out of area because local services cannot meet their needs, then consideration must be given to raising the skill level locally to enable service providers to better meet need. Short term external support can be given to providers in the shape of staff training or commissioning highly skilled professionals to work alongside existing staff and role model behaviours and interventions. Providers should be assisted to draw up detailed plans for managing difficult or challenging behaviours from individuals, drawing upon the skills of specialist staff in local authority or NHS services, or commissioned by these.