Tuesday, 19 April 2016

Secure attachment

This is the second short blogpost looking at recent trends in what’s happening with learning disability inpatient services in England to accompany the #7daysofaction campaign. This one looks at levels of ward security for people with learning disabilities in inpatient services in England from 2007 to 2015, using inpatient census information (see here http://www.hscic.gov.uk/searchcatalogue?productid=19718&q=learning+disability+census+2013&sort=Most+recent&size=100&page=1#top , here http://www.hscic.gov.uk/searchcatalogue?productid=20487&q=learning+disability+census+2013&sort=Most+recent&size=100&page=1#top and here https://www.improvinghealthandlives.org.uk/publications/1161/A&T_and_other_specialist_inpatient_care_for_people_with_LD_in_the_Count-Me-In_census ).

There is currently a lot of debate about different types of specialist inpatient service (particularly attempts to define Assessment and Treatment Units as fundamentally different to secure, forensic inpatient services), so I thought it would be useful to get an idea of trends in the number of people in these types of service over time. However, from 2007 to 2015 the categories of some types of inpatient service reported in censuses have changed substantially, and certainly from 2007 to 2010 underwent a time of definitional instability (with the number of people in services defined as ATUs going up and down so rapidly that this had to be a feature of how the same service defined itself over time rather than anything else - revealing in itself). So, as a relatively consistent measure of how services define themselves in terms of the ‘risk’ of the people they house, level of security (general, low, medium, high) seemed to be a better bet.

The graph below shows the number of people in learning disability inpatient services at general, low, medium and high levels of security, according to censuses conducted (with some gaps) from 2007 to 2015. As the previous blogpost reported (see http://chrishatton.blogspot.co.uk/2016/04/state-of-independents.html ), the overall number of people in learning disability inpatient services dropped substantially from 2006 to 2010, reflecting the tail end of ‘regular’ deinstitutionalisation, with slower change from 2013 to 2015.

If history is any guide, in a general process of institutional closure you would expect to see the biggest reductions in units at lower levels of security, and from 2007 to 2010 this is the pattern. The number of people in units at ‘general’ security levels dropped by 20%, with a further big drop in numbers to the 2013 census (although little change from 2013 to 2015). Amongst the specialist inpatient services that are left in England (where there are not supposed to be any generic long-stay hospital units any more) these presumably more or less map on to Assessment and Treatment Units.

The patterns are different at increasing levels of ward security, where you might expect general institutional closure programmes, in the absence of a specific focus on these types of unit, to have less of an impact. And from 2007 to 2010, this is again what we see; the numbers of people with learning disabilities in low secure, medium secure, and high secure inpatient services all stayed pretty static. Of course, in 2011 along came the Panorama programme on Winterbourne View, and the government and policy response specifically aiming to reduce the number of people in these types of inpatient settings. What happened next?

For people in low secure inpatient services, the number of people in low secure services in 2013 was roughly similar to the number of people in these services in 2010, with big reductions (a drop of 32% in 2 years) in the number of people in low secure services from 2013 to 2015.

However, the (smaller) number of people in medium secure services increased from 2010 to 2013, by 28%, and has stayed broadly consistent from 2013 to 2015. On a smaller scale yet, the pattern is the same for people in high secure services; an increase from 47 people in 2010 to 73 people in 2013, staying at a consistent level to 2015.



The increase in the number of people with learning disabilities in medium secure and high secure inpatient services between 2010 and 2013 is hard to understand, especially at a time when national policy was pushing in the opposite direction (and overall numbers of people in inpatient services were dropping). Did more people with learning disabilities really become highly dangerous between 2010 and 2013? Did something change in the criminal justice system, so that more people who would have ended up in prison before were diverted into medium and high secure inpatient services instead?Or are inpatient services adapting to new market conditions and creating more ‘specialist’ service niches that are more resistant to closure?


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