Friday, 20 November 2015

Impatient inpatient

The latest monthly statistics on the number of people with learning disability and/or autism in specialist inpatient units has been released today by the Health and Social Care Information Centre (HSCIC, see ). Six months ago I wrote a blogpost on these inpatient statistics (see ). At the time the statistics suggested the number of people in these inpatient units was not decreasing, but commissioners reported that 37% of people had a discharge date within the next 6 months. I foolishly wrote that if this prediction was right, we should see a significant dent in the number of people in inpatient units in 6 months’ time. What’s happened?

Well, on a nerd point, one big thing that’s happened is that the HSCIC have continued to try and improve the quality of the data they have. This leads to some complications when interpreting trends. This graph from the HSCIC executive summary neatly shows the problem.

The dark blue bars show the number of people in learning disability inpatient services steadily increasing over time (from 2,445 people in April 2015 to 2,620 people in October 2015) – this is based on the number of people that commissioners reported at the time. There are two reasons why this increase is hard to interpret though.

First, over time more CCGs are getting round to actually reporting any information to HSCIC (not like it’s a national priority or anything). In April 2015 the figures were based on returns from 167 commissioners (45 commissioners didn’t provide any information/updates, and 7 commissioners apparently didn’t have anyone in learning disability inpatient services). By October 2015, 189 commissioners were submitting information (26 commissioners still didn’t submit any information that month, and mysteriously the number of commissioners without anyone in inpatient services had dropped to 4). So – more commissioners reporting would suggest bigger numbers of people reported to be in inpatient services over time.

The second issue is in the light blue bars in the graph. As well as reporting the number of people for that month, commissioners can retrospectively report people in inpatient services that they didn’t report at the time - presumably people they’d only just found out about. These numbers are reported in the light blue bars. For April 2015, this adds 240 people (10%) to the number of people reported at the time. Each month, more and more retrospective people are added to the numbers, sometimes from several months back.

This means that we can’t interpret the overall numbers of people reported with learning disabilities in inpatient services as reducing over time either. Although the headline numbers drop from 2,685 people in April 2015 to 2,620 people in October 2015, by next April it’s possible that commissioners will have retrospectively added something in the order of 200-300 people to the October 2015 numbers.

Bearing all these caveats in mind, what is clear is that there has been no really significant drop in the number of people with learning disabilities in inpatient units over the past six months.

Most of the rest of the information in the HSCIC data tables is based on information submitted at the time by commissioners (so the dark blue line in the graph), which increases over time, so any changes over time have to interpreted in the light of this general ‘inflator’. Overall, the pattern is of no real change from April to October 2015, despite Care and Treatment Reviews and the nascent Fast Track Sites. For example:
·        The number of people aged under 18 in inpatient services (120 people in April; 135 people in October) – surely a priority?
·        The number of people with neither learning disabilities nor autism in inpatient services (90 people in April; 105 people in October) – why?
·        The number of people in inpatient settings that are not ‘secure’ (1,105 people in April; 1,190 people in October) - which you might expect would be the first group where you would see a reduction in numbers?
·        The number of people in inpatient settings that are not CQC compliant (280 people in April; 275 people in October) – where are the commissioners?
·        The number of people in inpatient services that are not subject to the Mental Health Act (305 people in April; 315 people in October);
·        The average number of days that people had spent in their current inpatient service (from an average 1,107 days in April to an average 1,118 days in October – that’s just over three years);
·        The average number of days in total that people had continuously spent in inpatient services, including transfers between different units (from an average of 1,894 days in April to an average of 1,942 days in October – that’s well over five years).

There are, however, some trend-buckers (have to be careful how I say that), all of which are going in the wrong direction:
·        The number of people in inpatient services who last had a review between 6 months and a year ago (up from 625 people in April to 965 people in October);
·        Even worse, the number of people in inpatient services who last had a review over a year ago (up from 30 people in April to a whopping 475 people in October);
·        The number of people in inpatient services who are reported to be ‘not dischargeable’ (up from 555 people in April to 655 people in October);
·        The number of people in inpatient services who do not have a planned transfer date (up from 1,290 people in April to 1,540 people in October).

There are some other worrying snippets that are hard to square with the latest NHS England/LDA/ADASS strategy “Building the right support”, more widely known I think as “Homes not hospitals” (see ).

First, only 575 people in inpatient services in October were reported to have a plan involving moving to ‘the community’ (this includes varieties of supported living and living with families), with a further 390 people having a plan to move to residential care. Most of the rest of people with a transfer plan (and bearing in mind that these plans don’t have to have discharge dates attached), have a plan to move to another variety of inpatient service.

Second, the most common ‘diagnostic category’ on admission to an inpatient unit was reported to be ‘learning disability’ (995 people in October 2015) – surely this should not be sufficient to get you into an inpatient unit?

Finally, there were 860 people in October 2015 where the local authority was not aware of a planned transfer to their local area. This may be because many people being ‘transferred’ are actually being transferred to other inpatient services, but it’s worrying in the light of the latest social care statistics that local authorities only report supporting 490 adults with learning disabilities in inpatient settings (see ). Despite the LGA/ADASS/NHS England strategy making much of its invitation to pool budgets across health and social care, a 'transformation fund' and a promise of dowries for those living in inpatient services for 5 years or more, it’s doubtful to me whether under the cosh local authorities are going to play.

I fear more Daisies on the horizon, a “home” for people for whom “living at home is not an option” (see ). As the Director of Quality for Wiltshire CCG describes it:

“This innovative service aims to provide individualised care and support for Wiltshire residents who have a complex learning disability with a mental health condition or display behaviours that challenge. This is a local residential setting which will encourage individuals to maintain their family relationships, build a fulfilled life through participation in the community and access mainstream services when required to ensure that their health and social care needs are met.” (see )

This is a nine-bedded ‘home’ being built in the grounds of a psychiatric hospital in Devizes, pretty central in the county but still three-quarters of an hour by car from the county town, Salisbury (going by public transport will take you an hour and a half, if you’re lucky). It’s called Daisy because its floor plan looks like a daisy, as can clearly be seen here.

I have nothing else to say.


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