Transforming Care: Leaving

This blogpost is the final one of five looking at the Transforming Care programme through the prism of the national statistics regularly produced by the ever excellent @NHSDigital.

The first blogpost looked at the overall number of people with learning disabilities and autistic people identified by the statistics as being in inpatient services.

The second blogpost looked at statistics on the number of people being admitted to inpatient services, and where they were being admitted from.

The third blogpost looked at when people were in inpatient units, how far were they from home and how long were they staying in inpatient services.

The fourth blogpost looked at planning and reviews for people within inpatient services.

This final blogpost will focus on the number of people leaving inpatient services (charmingly called ‘discharge’ or 'transfer') and what is happening leading up to people leaving. Again, even if the numbers of people leaving are not yet rapidly changing as a result of Transforming Care, the impact of the Transforming Care programme should be visible in the number of people getting ready to leave and how well people’s plans to do so are developing.

The first and most obvious question is whether people in inpatient services have a planned date to leave (I will pick up on the complications of what ‘leaving’ actually means later in this post). The graph below shows the proportion of people in inpatient services with a planned date for transfer, from March 2015 to September 2016 (according to Assuring Transformation data). There was a worrying drop in the proportion of people with a transfer date in 2016, but by September 2017 over half of people (55%) had a planned transfer date.

A date might be ‘planned’, but how distant in time is the planned transfer? The 5 columns on the left of the graph below show this information according to Assuring Transformation data, from March 2015 through to September 2017. Consistent with the earlier graph, the proportion of people without any planned date to leave at all increased hugely in 2016, with the position recovering throughout 2017. By September 2017, 11% of people had a planned transfer date within the next 3 months, 16% had a planned transfer date between 3 and 6 months ahead, and 9% of people had a planned transfer date between 6 months and a year ahead. For 13% of people their planned date to leave was between 1 and 5 years ahead, and for 7% of people their planned date to leave was overdue.

The right hand column of the graph shows equivalent information for August 2017 from the MHSDS dataset (see the first post in this series for details of the two datasets), which focuses more on people with learning disabilities and autistic people in more short-term mainstream mental health services. Possibly because of the mainly short-term crisis nature of people’s time in these services (in other words, people come in for a short period of time and leave again, with planned 'transfers' not part of the picture), the vast majority of people (87%) had no planned date for transfer. The second post in this series showed that a large proportion of ‘admissions’ to inpatient services were people transferred from acute hospital services and readmissions (where people had previously been in an inpatient service less than a year before) – what’s happening to people in these mainstream mental health inpatient services needs to be better understood. 

So far, the statistics look like there is a push from Transforming Care that is having an impact on the number of people with plans to leave. Do we know anything about the plans themselves? Well, if people are leaving the inpatient unit to go home in some sense then my expectation would be that the person’s local council should be aware of the plan to leave. The graph below shows information from Assuring Transformation based just on those people with a plan to leave – for this group of people, are councils aware of the plan? Over time, the proportion of people with a plan where their council is aware of the plan is dropping – from over two thirds (69%) in March 2015 to just over a half (53%) in September 2017. Just as worrying is that in September 2017, for a third of people (33%) it wasn’t known whether the council was aware of the plan or not, a huge increase from March 2015 (7%). At the very least this suggests that the close working between health and social care envisaged as central to Transforming Care is not universally happening. 

There are other signs too of potential haste in making plans to leave. The Assuring Transformation statistics report whether a range of people (the person themselves, a family member/carer, an advocate, the provider clinical team, the local community support team, and the commissioners) have agreed the plan to leave. For those people with a plan to leave, the graph below reports the proportion of their plans that have been agreed by different people, from March 2016 to September 2017. Over time, smaller proportions of plans have been agreed by anyone and everyone potentially involved. By September 2017, less than half of plans had been agreed by the person themselves (48%), a family member (44%) or an advocate (48%). Only just over half of plans had been agreed by the provider organisation (55%), the local community support team (51%) or the commissioners (55%). Even though not everyone will be in contact with family members to agree these plans, for example, to what extent are these actually feasible and sustainable plans that will result in a better life at home for people in inpatient services?

The final graph in this short blogpost series is one of the most important – how many people have actually been transferred from inpatient services, and where have they gone? The graph below adds up monthly ‘discharges’ from inpatient services in the Assuring Transformation dataset for two periods of time; a year from October 2015 to September 2016, and a year from October 2016 to September 2017. It’s also one of the most complicated graphs in this series, so I’ll go through it in a bit of detail.

The first thing to say is that overall the number of people ‘transferred’ from inpatient services has increased, from 2,050 people in 2015/16 to 2,235 people in 2016/17.

Of the people who have been ‘discharged’, in 2016/17 almost a quarter of people (525 people; 24%) moved to independent living or supported housing. Another fifth of people (450 people; 20%) moved to their family home with support, making nearly half of everyone ‘transferred’ from inpatient services.

Where did everyone else go? For over a sixth of people in 2016/17 (375 people; 17%) their ‘discharge’ was actually a transfer to another inpatient unit, confirming the picture of ‘churn’ of people passed around inpatient services found elsewhere in this series. Even more people (410 people; 18%) moved into residential care. Given that some inpatient services have re-registered themselves as residential care homes with the CQC, it is unclear to what extent people are leaving an inpatient service to move somewhere more local and homely, moving somewhere very similar to where they were, or not actually moving at all but staying in a place that has re-registered.

In 2016/17, there were also another 195 people (9%) who moved to an ‘other’ location – again it is unclear what these ‘other’ places are, but are they wildly different from where people were moving from? Finally, 120 people (5%) are in the puzzling category of ‘no transfer currently planned’ while having apparently already been transferred.

So in this final post in the series, there are definite signs that Transforming Care is exerting pressure for more people to have plans to leave their current inpatient services, and almost half of those people who are leaving are moving to independent or supported living or back to the family home. There are also some worries about the feasibility and sustainability of some of these plans, and the extent to which many people ‘leaving’ inpatient services are actually leaving for something radically different or being churned around a system that doesn’t call itself an inpatient service system but looks mighty similar to the people living within it.

One final point - I started this short series of blogs with a warning from @MarkNeary1 that all these graphs and numbers are people - and then I spent five blogposts talking only about numbers. I hope that numbers (which is what I spend a lot of my working life trying to understand) can give part of the picture and are useful in encouraging change, but I do worry if I'm 'assuring' myself that this the case. I want to leave the final word to a tweet from @nbartzis which sums up the whole issue perfectly.