Friday, 22 April 2016

Never let me go

To accompany #7daysofaction (see here for more details and heartbreaking stories ), this week I’m writing a series of short blogposts looking at the statistics we have about inpatient services for people with learning disabilities in England.

This post looks at what is included in both the annual Learning Disability Census and the monthly Assuring Transformation dataset about ‘care plans’. For me, this information is really about the assumptions that inpatient services are making about why people are there and what their prospects are for leaving again.

So, both datasets record ‘care plans’ under the following categories and sub-categories. First, there are people who ‘Need inpatient care according to the care plan’, including:
  • People who are not dischargeable at the time of the care plan
  • People who need indefinite inpatient care for behavioural needs
  • People who need indefinite inpatient care for physical needs
  • People who have an active treatment plan, but for whom a discharge plan is not in place

Second, there are people who ‘Do not need inpatient care according to care plan’, including:
  • People with a delayed transfer of care
  • People who are working towards discharge or have a discharge plan in place

The graph below shows the number of people at the end of September 2013, 2014 and 2015 who had care plans falling into these categories. What can we tell from this? Well, in 2015 over two thirds of people (68%) had inpatient service care plans indicating that they needed inpatient care, a proportion staying fairly steady from 2013 to 2015.

Within this group, however, there was a big change in 2014. In 2013, nearly half of all people in inpatient units (46%) had an ‘active treatment plan, but for whom a discharge plan was not in place’, but in 2014 this had dropped to just over a third of people (37%) and it stayed at this level in 2015. At the same time, the proportion of people deemed ‘not dischargeable’ rose from 15% of people in 2013 to 28% of people in 2014 and 2015.

Was this just an byproduct of slight changes to the definitions used for these categories in 2014, or does it reflect a general trend for more people in inpatient units to be counted as ‘undischargeable’ over time? More recent, monthly information from the Assuring Transformation dataset might give us some clues. The second graph below shows the ‘care plans’ of people in inpatient units month by month, from March 2015 to March 2016, using percentages rather than raw numbers.

Even over more recent times (so well after any one-off definitional change) the drift towards a greater proportion of people in inpatient units becoming ‘undischargeable’ over time is there, month by month. In March 2015, 21% of people in inpatient units according to this dataset were ‘undischargeable’; in March 2016 this was 26% of people (don’t ask me why this isn’t the same proportion as recorded in the 2105 Learning Disability Census – read this if you want to fall down that particular nerd rabbit hole ). This is an increase from 510 people in March 2015 to 675 people in March 2016.

In March 2015, 39% of people in inpatient services had an ‘active treatment plan, discharge plan not in place’. By March 2016 this had also increased, to 43% of people. This is an increase from 945 people in March 2015 to 1,135 people in March 2016.

Overall, the proportion of people ‘needing inpatient care’ increased from 61% of people in March 2015 to 71% of people in March 2016. What has happened in the course of a single year to lead to such an increase?

The flip side of this is the number of people who, according to their inpatient service care plans, don’t actually need to be in inpatient services at all. Overall, from the census data, this was just over a third of people in inpatient units in September 2013 (34%; 1,105 people) and just under a third of people in September 2015 (32%; 950 people). From the Assuring Transformation data, the trend is more pronounced, from 39% of people (915 people) in March 2015 to 29% of people (785 people) in March 2016.

A reduction in the number of people in inpatient services who don’t need to be there according to their (inpatient service written) care plans is to be welcomed. But when this happens at the same time as an increase in the number of people who do need to be there according to their inpatient care plans, it begins to look like a defensive reshuffling of the pack for inpatient services to justify their continued existence.

The final graph for this post shows the consequences of this for getting people out of inpatient services. It shows the percentage of people in inpatient services with a planned date for transfer (note that this doesn’t necessarily mean leaving inpatient services altogether, as this could include people being moved to a different inpatient service), from March 2015 to March 2016. The proportion of people in inpatient services with a planned date for transfer has dropped drastically in just a year, and is heading in the opposite direction to Transforming Care policy. In March 2015, half of people in inpatient services (50%; 1,200 people) had a planned date for transfer. By March 2016, this had reduced to less than a third of people (30%; 775 people).

Much has been made by inpatient service providers of people not having anywhere to move to as a reason why some people are kept in inpatient services so long. According to these statistics, they’re being a little disingenuous. At the end of March 2016, apparently only 65 people (a reduction from 85 people in March 2015) were in inpatient services because of a delayed transfer in care, with a wide range of reasons for these delays. If inpatient services were fearlessly preparing people for life outside the inpatient service, only to be blocked by nefarious local authorities, then these numbers would be much, much bigger. I’m not saying that some local authorities and others aren’t evading their responsibilities too.  I’m saying that perhaps some inpatient services aren’t trying quite as hard as they claim to get people out?


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