Monday, 25 March 2019

Transforming Care report card 1: People being admitted to inpatient units

Towards the end of 2017 I did a five-day series of blogposts (you lucky people…) on the progress of Transforming Care in reducing the number of people with learning disabilities and autistic people in inpatient units (see here for the first of the five), according to the available statistics. As Transforming Care does or does not come to an end at the end of March 2019, I thought it might be useful to update four of these five blogposts. Leaving aside the issue of the overall number of people in these inpatient units (I’m confident this will be covered elsewhere), I want to look again at some of the other statistics that give us some clues about what has been happening with Transforming Care and what we might expect to find in the near future.

These blogposts will focus on information produced publicly by NHS Digital from two datasets. First, the Assuring Transformation dataset – for this dataset, health service commissioners provide information (sometimes retrospectively) on the number of people with learning disabilities and autistic people in specialist inpatient services and on various aspects of what is happening with or to people. I’ve collected some of the information into six-month or yearly blocks, and some of the information I report for every three or six months rather than every month (both you and I would not survive that amount of information…). This means that most of the information goes up to September 2018 or at the latest December 2018. Second, the Mental Health Services Dataset (MHSDS – also available via this web address), which reports information collected by mental health service providers concerning people identified by them as a person with learning disabilities or an autistic person – this has been published monthly starting more recently than the Assuring Transformation dataset and is less detailed about processes. In different ways both datasets are partial – Assuring Transformation does not include a lot of people in mainstream mental health inpatient units, and some big independent sector inpatient service organisations are not yet reporting to the MHSDS.

As with the previous series, these four blogposts will focus on:
  • Who is going into inpatient services?
  • How long are people spending in inpatient services?
  • What planning and review is happening in inpatient services?
  • What is happening about people leaving inpatient services, and where are they going?

So – much of the focus of the Transforming Care programme has been on getting people out of inpatient units, but the slower than planned reduction in the overall number of people in these units suggests that there are still substantial numbers of people coming into these units. What do the statistics tell us about this?

Every month, the Assuring Transformation statistics report how many people have come into an inpatient unit (called ‘admissions’) according to commissioners. The graph below adds these together across three different years, October 2015 to September 2016, October 2016 to September 2017, and (you guessed it) October 2017 to September 2018), so we can see the number of people coming into these units and whether they have changed over time.

The first thing the graph shows us is the overall number of admissions to inpatient services is still increasing, from 1,810 admissions in 2015/16 to 1,980 admissions in 2017/18. The second thing to notice is that an increasing number of admissions (the red chunk) are actually transfers from other hospitals (mainly other inpatient services of various types), with a sharp increase in 2017/18 up to over a quarter (28%) of all admissions. This churn around the inpatient service system is something that will feature in later posts too, and it seems to be increasing rather than decreasing. The third thing I want to mention is that more than one in six admissions (the lilac chunk, 18% in 2017/18) are readmissions, where people had previously been in an inpatient service less than a year before – the number of these people are increasing over time too. Finally, the purple chunk shows that just over half of admissions to inpatient services (55% in 2017/18) are people who have not been in an inpatient unit for at least a year (or maybe never).

Information from the MHSDS tells a very different story. The graph below shows information on how many times people with learning disabilities and autistic people have been admitted to inpatient units/wards, for just six months (April to September 2018). The most obvious thing is the headline figure of 9,950 admissions in six months, a rate of people being admitted 10 times higher than that reported in the Assuring Transformation dataset. What does this vastly higher headline figure include? First, it includes a lot of admissions of inpatient units for the purposes of ‘respite care’ – there were 2,745 occasions (28% of admissions) when people were admitted for respite care in these six months, and for almost all of these episodes of respite care (94%) the person was in and out of the unit for a short period of time, within the same calendar month (other people may also have been in for short periods of time but just crossing the boundary of a calendar month). In the same six months there were 7,205 admissions to inpatient units ‘not for respite’ purposes. Just over half of these admissions (3,750 admissions, 52%) were for people who went in and out of the unit within the same calendar month. The MHSDS is clearly providing a completely different picture to the Assuring Transformation dataset, mainly because it is recording a huge number of people going into and out of (mainly general mental health) inpatient wards for short periods of time and for a range of reasons (are inpatient units the most appropriate place for ‘respite care’?). Transforming Care as a programme seems to be paying no attention to the experience of these large numbers of people with learning disabilities and autistic people.

What kinds of places are people being admitted to inpatient services coming from? The graph below shows this information from the Assuring Transformation statistics, for two one-year blocks, October 2016 to September 2017 and October 2017 to September 2018. Even from one year to the next, the picture is changing.

In 2017/18, 40% of people (760) were admitted from their ‘usual place of residence’, down sharply from half of people (51%; 935 people) in 2016/17. In 2017/18, getting on for half of all people admitted to inpatient units (49%; 935 people) were admitted from other inpatient and/or hospital services, particularly from ‘acute beds’ (which presumably includes people being transferred from mainstream mental health inpatient services) – sharply up from 2016/17 (37%; 680 people). A further 100 people (5%) in both 2016/17 and 2017/18 were admitted from ‘penal establishments’ and similar numbers of people (125 people; 7% in 2016/17; 115 people; 6%; in 2017/18) were admitted from residential care services.

Overall, it seems like the pressures are continuing to build, for which inpatient services are being used as a response, with an increasing number of people being ferried straight from one inpatient service to another or being re-admitted after a short time out of an inpatient service. While it might be a marker of progress for Transforming Care that fewer people are coming into inpatient units from their ‘usual place of residence’, the increasing number of people being churned around the inpatient system and being re-admitted into inpatient services are clear markers that inpatient services are not doing their job and the support that people are getting on leaving inpatient units may not be enough. The MHSDS dataset also presents a worrying picture seemingly ignored in the Transforming Care programme, of large numbers of people going into mental health inpatient units, often for short periods of time. Does this help people, or is it another sign of a potentially increasing lack of decent community support? These are questions that Transforming Care, or any potential successor, needs to urgently deal with.

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