Sheffield Health and Social Care NHS Foundation Trust

Case study summary

Sheffield Health and Social Care Foundation Trust aim was to develop efficiencies and improve the quality of provision in terms of the use of inpatient beds and patient flow to ensure that people of Sheffield were able to access inpatient acute and rehabilitation care when it was needed without the need for out of city bed use.


In 2012 acute mental health bed occupancy in Sheffield was running at 120%. Alongside this there were large numbers of people being placed out of city due to a lack of inpatient beds, including Psychiatric Intensive Care Unit (PICU) care and people who required locked rehabilitation care.

Sheffield Health and Social Care Foundation Trust aim was to develop efficiencies and improve the quality of provision in terms of the use of inpatient beds and patient flow to ensure that people of Sheffield were able to access inpatient acute and rehabilitation care when it was needed without the need for out of city bed use.

Seven Key objectives:

  1. Reduce length of stay. In order to maintain patient flow within the inpatient care it was necessary to develop strategies to reduce the length of stay and improve the flow of patients. Productivity work has taken place and length of stay is managed using a range of methods including: daily bed management for all wards together; daily ward team meetings with the consultant: discharge coordinators based on each ward.
  2. Develop crisis care- across the city. A crisis house was commissioned (run by Rethink for all age groups over 18 years) and enhanced crisis and home treatment teams across the age range. Including, psychologists on inpatient wards, improved environments with, for example, increased de-escalation space, a new Psychiatric Intensive Care Unit
  3. Establish leadership roles in weekly bed management meetings. The bed management meetings focus on the flow of service users between the inpatient and community services. This supports and encourages the use of alternatives to admissions to the ward such as the crisis house and home treatment teams.
  4. Establish a strong senior management team to drive through the changes. This has a supportive presence across the inpatient pathway, offering a coaching and mentoring leadership focus.
  5. Reduce out of area spends on out of city or private provision for psychiatric intensive care – the provision of psychiatric intensive care beds was too small for the city and the unit not fit for purpose. The trust developed a purpose built, 10 bedded psychiatric intensive care unit – Endcliffe. This new unit accommodates the service user demand in city to avoid out of area admissions / treatments.  The new environment provides a therapeutic, safe space and provides three outdoor spaces, de-escalation/green room, dedicated multi-faith room, sensory room and activity spaces, which includes a cardio wall to promote physical health. The new unit also includes improved facilities for staff including separate staff rooms away from the ward, shower room and individual alarm systems to be able to request immediate assistance from anywhere on the unit.
  6. Reduce out of area spends on private provision for treatments in mental health locked rehabilitation services. The trust have so far returned 23 people (to live in their own flats in the community in Sheffield) from locked rehab out of area treatments. The CCG invested £2 million in the new Community Enhancing Recovery Team and still saved considerable sums of money. Out of area treatment bed nights for these patients has been reduced by 99%.
  7. Improve the quality of care offered in the inpatient environments. The trust introduced collaborative care planning: using RESPECT techniques to replace more restrictive interventions- these are joint sub projects with experts by experience and staff working collaboratively to achieve a culture change.

The impact of these interventions substantially reduced length of stay from 56 to 31 days and greatly improved pathway management. The trust has gone from having two older adult wards (22 beds for each ward (44 beds in total) to one older adult ward (18 beds). They have moved from having four acute adult psychiatric wards with 24 beds each (96 beds) to three adult wards all 18 beds each, (54 beds in total).

Each ward has kept its existing staffing levels therefore increasing the staff to service user ratio, to enhance the therapeutic contacts on the ward, promoting recovery focused care. More importantly they have eliminated out of area treatments for acute beds and PICU due to lack of capacity for over a year. During this time there has been a maintained or slightly higher level of admissions and much better access to acute care. In April 2016 they closed one adult acute ward as this was no longer needed. They are using some of the savings from this ward closure to invest in enhanced home treatment teams and community services for people with a personality disorder ensuring access to NICE guideline based interventions.

The total bed reductions over this time, including constant out of area bed use, has gone from 160 beds down to a new model in 2016 of 72 acute beds across the age range. There have been no out of area acute admissions due to lack of capacity.

The project to transform acute care used the existing budgets for acute inpatient care and out of town spend which was approximately £10 million to improve services. This has involved increasing the staffing ratio and the skill mix on the remaining wards. The skill mix now has more registered nursing staff and psychological input.

Capital money, saved through efficiencies, was used to build the Psychiatric Intensive Care Unit. The cost of this and enabling works was £6.1 million. This is the start of the capital investment programme to develop the inpatient wards and establish healing environments. Money released from the inpatient system, (the closure of two inpatient wards) has allowed £2.3 million investment into  community services to enhance the home treatment teams and further develop  the personality disorder services. The transformations in the rehab system have been focused on releasing the £6.1 million spent out of area on locked rehabilitation per year. The rehabilitation system has been developed and they now have the community enhancing recovery service. This has relocated care of service users back into their locality and into the community.

In the first year this released a system saving of over £1 million.


There are a range of methods by which evaluation is carried out. These include:

  • Service user focus groups including the crisis house and PICU.
  • Quality and dignity surveys, carried out regularly. Service user leads visit the services and carry out the survey with existing service users.
  • Review of key performance and quality indicators through regular service meetings as well as the reconfiguration programme board.
  • Regular updates to trust board about progress and review data. This includes the levels of restrictive interventions, incidents and levels of acuity.
  • All progress is actively monitored.
  • Service user flow is monitored and managed weekly through bed management and the community flow meeting.

Data suggests that all is going well with no increase in the number of incidents. The reduction in length of stay has allowed a reduction in bed numbers. This in turn has released funding to improve staffing levels on the inpatient wards and enable investment into community alternatives.

Tips for adoption

  • Having a project lead and effective governance structures with administrative support.
  • Joint working across the community and inpatient services so that all staff are able to view changes in the context of the wider system.
  • Joined up working with our estates department and clinical team
  • Carry out a wide range of engagement including questionnaires, focus groups, walk rounds.