Background: Non-forensic placements within the independent sector represent one of the largest parts of the care system for adults with severe and enduring mental illness. Aims: To describe a cohort of patients placed out of area in one voluntary sector and 11 private sector open (non-forensic) facilities by one PCT and Social Service authority. To provide empirical evidence on the care they receive. Method: A purpose-designed survey instrument based on patient and staff interviews and analysis of documentation (casenotes, careplans, risk assessments, prescription cards) examining 70 (100%) adult patients with severe and enduring mental illnesses placed out of area of origin. Results: Significant numbers of patients were not in receipt of CPA (45/70, 64.3%) or multi-disciplinary review (44/70, 62.9%), most were locked within facilities although informal patients (55/70, 78.6%), clinical and treatment histories were absent in half of the cases (35/70, 50.0%) and many needed supported accommodation rather than independent hospital or nursing home care (19/70, 27.1%). Involvement of patients (19/70, 27.1%) and relatives (30/70, 42.9%) in care planning was limited. Placement costs for 2003/04 was £2,160,662 (mean = £30,867). Conclusions: Closer collaboration between NHS providers, service commissioners and the independent sector is required to ensure greater consistency in quality of care and to prevent patients from being lost from the commissioning system. The role of regulators requires review in light of these findings. Declaration of interest: None.

The rate of emergency referral is one indicator of the functioning of the service system as a whole. Improvements to the system should include better access to community mental health team services and a greater capacity of the primary care system to manage mental health crises. Services need to be developed that are acceptable to male patients who are experiencing social and behavioral problems.

For patients compliant with SDOs, the pressures necessary to treat effectively need not involve powers to enforce medication compliance.

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