Working together
Millions of pounds have been pledged to discharge individuals with learning disabilities or autism into community provision. Eleanore Robinson investigates why things have been slow thus far
The government announced in last month’s (March) budget £74m of funding over the next three years to speed up the discharge of individuals with learning disabilities or autism into community provision from mental health inpatient care in England.
The money was initially pledged in the Conservative Party Manifesto ‘for additional capacity in community care settings for those with learning disabilities and autism’.
This comes eight years after the coalition government pledged to discharge every person with learning disabilities and autism from hospital assessment and treatment units (ATUs) who did not need to be there.
Since then targets have been repeatedly missed and new admissions and readmissions continue.
At the end of February 2020, there were 2,170 adults with learning disabilities and autism in ATUs. While more inpatients were discharged (130) than admitted (95) during this month, only 70% went to community settings. More than half of those discharged had been in hospital for more than two years.
Of the inpatients still there, 46% were in a secure ward. Those aged between 25 and 34 years old accounted for the largest proportion of inpatients at 29%.
There is less than 30% chance among 20-29 years olds with learning disabilities or autism of being in a care home or supported living accommodation, according to LaingBuisson.
Dan Scorer, head of policy and public affairs at Mencap, which has campaigned for the timely discharge of people from inpatient units, said while targets were set for getting people out of hospitals, there were none to develop community support services.
‘The focus has been to drive down bed numbers,’ he explained. ‘For people coming out of these institutions, they are traumatised. It is not easy for people to make the transition. The first year for many people is really difficult.’
He added that, despite the establishment of Transforming Care Partnerships to smooth the discharge process, support for people can be patchy.
NHS England statistics show the already postponed target of only having 37 adult inpatients per million of the population by 31 March 2020 was only achieved in the East of England and South West regions. In the North West and Midlands it was 52 per million and 55 per million respectively.
Bill Mumford, former programme lead for the Joint Improvement Board, which was tasked with overseeing the transition of inpatients to community facilities after the Winterbourne View scandal in 2011, said the slow progress was due to the Transforming Care programme coinciding with a decline in the number of community learning disability nurses and cuts to health and social care budgets during austerity.
He said that for the NHS moving people out of ATUs was not a top priority at the time.
Furthermore, some providers who were struggling in the homecare market moved into supported living. ‘I think there has been a certain amount of overreaching with providers saying they have got the competence,’ he said.
Mumford added that while there were many good examples of local services, providers and families working well together to prevent admissions and readmissions, this good practice was not widespread enough to reach critical mass and impact the numbers.
‘It is naïve to think you can scale down the centres and the community would pick up the slack,’ he said.
Supported living provider Dimensions, is finding the remaining inpatients are no longer those who have been in ATUs for long periods of time because there was no other accommodation for them. It is a more complex group who have had a crisis and been transferred to hospital as there was no other suitable place of safety in the community.
Head of marketing and external relations Duncan Bell said one particular issue is that the individual is often surrounded by people who have lost faith. But given the right support, the experience is that most people can live successfully outside of ATUs.
Of the 95 admissions to hospital in February, 20 were readmissions within a year of the previous discharge. Bell added: ‘A failed placement and readmission makes it really hard the next time. Both the individual and the clinician will believe it is not possible.’
However, by different organisations working together to put the best package and staff around the person can make all the difference. He said: ‘I think partnership working can be particularly advantageous. Often one organisation has a strength that others could take advantage of.’
Scorer agreed saying: ‘The key thing is joint working between services. Pooling budgets to agree the best outcomes. The areas that are seeing success are working together.’
He said it was also important to consider the needs of children and young people, so they do not enter the system in the first place.
Bell added community providers should be involved as soon as possible after hospital admission.
He said: ‘They need to involve care and housing providers very early on so we can look at what they need and build that relationship with that person so when the time comes it is a relatively small step.
‘One area it does not always work is between the provider and the hospital themselves.’
He said Dimensions had experienced hospitals restricting prospective supported living staff visiting patients to build up a relationship or sharing their knowledge of the individual because ‘they are going to lose business’.
‘We do find bad partnerships between the outgoing and incoming providers,’ Bell added.
In addition, not all care and treatment plans are being carried out within the required timeframe of six months. NHS England figures show that in February, almost a third of inpatients last had a review of their care more than six months ago.
Furthermore, not all of them meet the requirement to include a discharge plan, Bell said, which should be sanctioned by the NHS.
Despite these delays, there has been some positive developments.
NHS England is now moving money across to follow people into the community under a ‘dowry system’, but this is only for those who have been in ATU’s for more than five years.
Mumford said: ‘There are steps towards more investment on this. There has been a structural shift which is positive.’
‘It is the right idea,’ agreed Scorer. He argued having the funding with the NHS disincentivises the growth of community services. ‘The budget announcement is a similar idea [to the dowry system]. Half a billion pounds is being spent on the wrong kind of care and that money could be released.
‘We want to see a different model in the community used for short periods and move away from large institutions in remote places,’ he said.
‘The model should be very short assessments,’ agreed Mumford. ‘Beyond that there is no evidence that people improve. The evidence suggests quite the opposite. The challenge is to get people to stay out and not go in, in the first place.’
He said more intensive care outreach services were needed with psychologists offering therapy and short-term treatments. Furthermore, a discussion needs to take place about what that model should look like and how to shape services and upskill families and community-based provision.
Bell added £74m would not be enough to support 2,000 people to leave assessment centres. He said: ‘What we need to see is local authorities being funded properly so the cost of supporting people in hospital is transferred in full.
‘They [clinicians] need to believe in the individual more. It is the system that has failed the person not the person’s inability to live in that community.’
The Department of Health and Social Care and NHS England were unavailable for comment.