Out of area placements are not just an operational problem

The discussion opens with the reality of what out of area placements mean in practice. Harris sets out both the human and financial costs – patients placed far from their support networks, poorer experiences of care, and costs that can be roughly double those of a local equivalent stay.

But the conversation quickly moves beyond the headline numbers. As Mikoto reflects, the phrase “out of area” itself points to something important – a form of distance and dislocation that goes beyond geography. She describes the issue as fundamentally relational, noting that it creates distance “between people who are receiving care to those who are providing it” and also between staff and the wider networks around a patient.

That focus on the relational dimension is one of the defining strengths of the episode. It is a reminder that out of area placements are not just a flow problem, a bed problem or a throughput problem, important though all of those things are. They are also a problem of belonging, familiarity and connection.

What the programme set out to do

The work with Sussex Partnership NHS Foundation Trust formed part of a two-year programme, with The PSC supporting the final six months. As Mikoto explains, the model was deliberately “locally led and centrally supported” – combining central programme discipline with local ownership and adaptation.

The aim was to reduce length of stay on adult inpatient units and eliminate inappropriate out of area placements by working closely with frontline teams across the trust. That meant not only identifying evidence-based initiatives, but helping staff test, embed and scale them in the middle of very significant day-to-day operational pressure.

As Mikoto puts it, much of the work involved “hands-on support and coaching methods” so that frontline staff felt empowered and confident to make change happen. That emphasis on capability and confidence is important. The programme was not something done to teams. It was something built with them.

Operational detail and clinical nuance

One of the most interesting features of the conversation is the way Harris and Mikoto describe the mix of interventions involved. This was not a single silver bullet. It was a portfolio of initiatives that ranged from detailed operational practice to thoughtful clinical redesign.

On the operational side, teams were supported to make multidisciplinary huddles more effective – using those meetings to clarify the next action for each patient, strengthen progression planning and improve flow through the wards. On the clinical side, the programme supported initiatives such as positive wellness and wellbeing plans, helping patients identify strengths, build coping strategies and recover more quickly.

As Harris reflects, it was that blend of “quite detailed operational stuff” and “quite thoughtful clinical stuff” that made the work particularly interesting. In practice, the two could not be separated. Better patient flow depended on better care, and better care depended on better systems and routines.

Mikoto adds another layer to this by reflecting on the ambiguity involved in some of the pathway redesign work, especially for people with complex emotional needs. There were no easy answers. Teams were often trying to reduce unnecessary length of stay while avoiding the risk of becoming too reductive or neglectful in how care was provided. The work therefore demanded presence, careful judgement and a willingness to sit with uncertainty.

Results that mattered

The programme delivered significant results. Compared with the starting point in September 2022, inappropriate out of area placements were completely eliminated and that elimination was sustained. The programme generated a recurring monthly saving of around £100,000 and engaged 22 inpatient wards in embedding evidence-based improvement initiatives.

Those are substantial outcomes by any measure. But one of the strengths of the discussion is that it does not stop at the metrics.

Mikoto reflects that what has stayed with her most strongly is not only the “story of the big numbers” but the experience of “sustaining meaningful momentum for impactful change” and “reclaiming possibility” from the frontline. In pressured environments where teams can easily feel trapped by crisis management, that sense that change is still possible is itself a major achievement.

Culture changes through action

The conversation offers a valuable reflection on how cultures of care change in practice. Harris makes the point particularly clearly, arguing that culture is rarely improved simply by discussing culture at length. Rather, it changes when people start doing things differently together.

As he puts it, “it was the action that drove the behaviour and mindset shift… rather than the other way around.” That is a useful insight not only for mental health transformation, but for organisational change more broadly.

Mikoto builds on this by describing the importance of a shared commitment to “compassionate, supportive and proactive” ways of relating to one another. The centrally supported programme model helped set a standard for how people came into conversations – not only with pace and discipline, but with presence and care. In that sense, the method of delivery was itself part of the cultural intervention.

What this means for the future of mental health care

The final part of the episode looks beyond the programme to the future. Mikoto points to international examples and community-based alternatives that challenge the assumption that mental health care must be organised around placement in inpatient settings. She references the Trieste model, crisis cafés, safe havens, crisis houses and Zimbabwe’s Friendship Bench as examples of support that is visible, local, relational and less medicalised.

Her framing is striking. What if the long-term answer is not just to get better at managing placements, but to rethink the whole model that makes placement the default in the first place?

That reflection leads to one of the strongest ideas in the episode – the suggestion that rather than simply finding places to put people in distress, society might need to “place ourselves alongside” them. Harris offers that phrase towards the end of the conversation, and it lands because it captures the deeper ambition behind the operational work. Reducing out of area placements is not only about efficiency. It is about bringing care closer to home, strengthening community responses and rethinking what support looks like when it is built around proximity and relationship.

Closing reflection

This conversation is a reminder that quality transformation in mental health is never only about targets, beds or pathways, important though all of those are. It is also about the culture in which care is delivered, the confidence and agency of frontline staff, and the extent to which services help people stay connected to the places and relationships that matter to them.

Reducing out of area placements is therefore not a narrow operational challenge. It sits within a much wider agenda of mental health quality transformation – one that includes cultures of care, relational practice, community-based alternatives and more humane, sustainable models of support.

The PSC is a specialist management consultancy dedicated to making public services brilliant. If you'd like a further conversation on how we can support your organisation with mental health quality transformation, get in touch with Harris Lorie – we'd love to chat.