Secure Services Referral and step down pathway: Managing access to internal and external secure beds

Sherilea Curzon, Senior nurse LSU, PICU and Carmarthen Adult Mental Health

Nicola Hopkins Lead Nurse for commissioning team

Kay Isaacs, head of Adult Mental Health

Caitriona Quinlan, LSU and FMHT manager

Hywel Dda University Health Board


The relationship between the health boards Low secure unit and Psychiatric intensive care unit in respect of both internal and external referrals was fragmented . There was no established pathway into externally commissioned hospital beds.

A proposal was made to establish a multi- disciplinary team meeting with an associated panel to manage all new referrals by scrutinising these referrals and exploring local options. We needed a pathway that would provide a single integrated approach with appropriate clinical governance and decision making arrangements and clear budgetary and commissioning governance for high cost external placements.

Project Aims

The aim of the project was to review long term admissions in the low secure unit (over 18 months). For the MDT to take a lead role in the decision making process in respect of these patients alongside:

  • Establishing an MDT referral meeting incorporating a panel consisting of Commissioning team, Head of adult Mental health, Lead Consultant Psychiatrists, LSU and PICU Psychiatrists and managers.

  • Scrutinising all internal and external referrals including requests for our LSU beds and Prison transfers to PICU/ LSU.

  • Managing waiting lists

  • Monitoring and review HDUHB individuals placed in low, medium and secure placements.

  • Specific monitoring of prison referrals

  • Managing a review process with probation and police in accordance with Multi Agency Public Protection Arrangements ( MAPPA).

  • Provide budgetary and commissioning governance for high cost external placements

  • To ensure all local options are explored and a clear clinical rational with step down plan provided.

  • Co-ordinate discharge ensuring holistic support services and relevant agencies/ professional bodies are in place to meet individual needs.

A forum was needed with Senior staff to scrutinise requests for external placements and to justify these costs and to understand why the needs of the patient could not be met locally and also to look at step down options .


After running this bi- monthly Low secure pathway meeting for 7 months, a SWOT analysis by members was completed highlighting the following challenges:

‘Meeting can sometimes focus too heavily on specific cases and the views of the ward. Difficult to challenge the views of the Consultant and open up discussion about alternative options to progress discharge earlier. We haven’t got the discussion about commissioned placements part quite right yet but hopefully next meeting will progress and include care co-ordinators’,

‘Need to ensure that the meeting has a supportive focus but does direct where needed. Need to maintain attendance and ensure it is prioritised’.

‘Some cases take a lot of time, there are times when this will be the case however the same conversations can be had at meetings after meeting. There isn’t a structured approach to discussing/recording referrals. This means we could be missing themes in the reason people are going to other hospitals. Also, a completed form could accompany the high cost request. HDUHB clients are not discussed in the same way external hospital clients are. There is no invite to anyone from therapies.’

‘On occasion not having the correct people at the meeting can slow down discussions on external placements. Slowing down the move- on if we have to wait for agreement when the meeting is only 2 weekly and lack of care co-ordinator involved as we can’t make move on plans without them.’

Keeping staff interested in the Bevan Exemplar was quite challenging and I felt at times I was on my own with it as one other staff member that started it with me left the health board.

Next Steps

  • To finalise the terms of reference

  • To ensure that the meeting attendance is maintained and that it remains a high priority meeting.

  • To get Care co-ordinators to start to attend when requesting placements for their clients.

  • To develop a structured approach for discussing and recording referrals.

  • To look at extending invites to the meeting to others when appropriate such as from ‘therapies’.

  • Finding ways to ‘open up’ the discussion so that challenges can be made but in a supportive way.

  • Finding a way to ‘time limit’ some of the discussions and to ensure the discussions are not monopolised by individuals.

  • Format a way to monitor those in secure placements and their progress so that we can move clients to the least restrictive placement.

  • Embed the MAPPA process which has just begun in the context of the Low secure pathway meeting.

  • Monitor number of prison referrals and the outcome of those admissions.

Our Exemplar Experience

The Bevan Exemplar experience was really interesting and a fantastic resource with all the advice and extra sessions available. I did not enjoy the ‘break out rooms’.

I found it difficult to protect my time to attend these sessions and it meant that I often had to work late on these days to keep up with my work.


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