A price worth paying?

To accompany #7daysofaction, 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. The stories in #7daysofaction (see here https://theatuscandal.wordpress.com/ ) show us the real cost in the blighted lives (and sometimes deaths) of people with learning disabilities and the impact on their families.

There is also a financial cost (or more strictly speaking a financial charge, for these two things are not the same) for these inpatient services, paid for by the state. This blogpost looks at the charges made for these inpatient services, as collected by the Health and Social Care Information Centre in the Learning Disability Census from 2013 to 2015 (see http://www.hscic.gov.uk/catalogue/PUB19428 ).

The graph below shows the amount charged, per week, for a place in an inpatient service in England.

First, there is a huge range of charges per week – the extent to which this range maps on to ‘need’ (whatever that might mean) is unclear. So in 2015, 115 people were in inpatient units charging less than £1,500 per week (or £78,000 per year), while 130 people were in inpatient units charging more than £6,500 per week (or somewhere north of £338,000 per year).

In 2015, the average charge for an inpatient unit was £3,563 per week (up slightly from an average £3,426 per person per week in 2014, a 4% increase). This equates to £185,276 per person per year. Across 3,000 people, that’s £556 million per year paid by the state to keep people in inpatient units.

While the number of people in inpatient units dropped slightly from 2013 (3,250 people) to 2015 (3,000 people), the number of people in the most expensive units, charging £4,500 or more per week, has actually increased from 2013 (369 people) to 2015 (440 people).

It also turns out that independent sector services tend to charge higher prices than NHS services. On average, independent sector units charged £3,700 per person per week in 2015, compared to £3,449 per person per week in NHS units. While independent sector services accounted for 44% of all places charging less than £4,500 per person per week, they accounted for 52% of all places charging more than £4,500 per person per week.

Who is paying these charges for inpatient services? Well, apart from the obvious answer of “We are” (think of how over  half a billion pounds a year could be used to support people with learning disabilities in England), the Learning Disability Census does contain a breakdown of who is paying for what. My eyebrows (which I thought couldn’t go any higher) were raised further at various points. So, in no particular order…

• NHS Clinical Commissioning Groups. In September 2015 they were paying for 1,335 people in inpatient services (down from 1,575 people in 2014), at an average charge of £3,424 per person per week.
• NHS England specialist commissioners (who are more likely to be paying for people in secure inpatient services than CCGs). In September 2015 they were paying for 1,470 people in inpatient services, up from 1,395 people in 2014. These are the commissioners under the direct control of NHS England, with the stated policy aim of drastically reducing the number of people in inpatient units. They paid an average £3,645 per person per week.
• Other NHS commissioners outside England. In September 2015 they were paying for 75 people in inpatient services in England, up from 55 people in 2014. Although small in number, these places are particularly lucrative – the average charge for these commissioners was a whopping £4,419 per person per week.
• Other NHS providers. I’m struggling to understand how this would work, but it’s presumably NHS Trusts sub-contracting to other organisations when they can’t provide an inpatient place they've promised. In September 2015 the number of people was small (25 people, compared to 35 people in 2014) – they paid £3,354 per person per week.
• Commissioners using pooled health and social care budgets were paying for 10 people in inpatient services in September 2015, down from 20 people in September 2014, at a bargain basement price of £2,926 per person per week.
• The final group of commissioners where my eyebrows almost met my receding hairline were local authorities. In September 2015, local authorities were paying for inpatient places for 80 people – admittedly a sharp reduction from the 150 people they were paying for in 2014. They paid an average £3,738 per person per week, including places for 10 people charged at more than £6,500 per week each.

What does this tell us? Well, for one thing there’s a shed-load of cash tied up in inpatient services, and £556 million is a more than tidy sum for reinvestment into something better. For another thing, commissioners of all sorts are prepared to pay through the nose for these places, sometimes in defiance of their own organisation’s national priorities. Finally, in a time of alleged austerity, the cost of these places is going up, and the expansion is in the really, really, really expensive ones. Are commissioners going by the principle of “Reassuringly Expensive”?