Winterbourne View 12 Years On - 2023. Report card 1: People being admitted to inpatient units, legal status and ward security

It is now more than twelve years since the BBC aired its programme about the horrendous abuse meted out to people with learning disabilities and autistic people at Winterbourne View, a ‘specialist’ inpatient unit.

Has nothing really changed at all in this 12 years, with the panoply of policies, progress reports, rebranded initiatives when previous ones have not met their targets, meetings, deep dives, reviews, flow charts, workshops, more reviews, and days, weeks and years of people’s lives living in spaces beyond human rights and dignity (not to mention the amount of public money that must have been spent on officials to get a ‘grip’)?

There are many ways to try and answer this question. One thing I’ve been doing sporadically is to look at the official monthly statistics published by NHS Digital (now absorbed into the NHS England empire) about autistic people and people with learning disabilities in inpatient units, to see if they reveal any tangible evidence of change over time (or at least since 2015, when some of this information began to become available). The last time I went through a comprehensive ‘report card’ on inpatient units was in the summer of 2022, in a series of four blogposts (the link to the first one of these is here). I’m going to update this 'report card' in four similar blogposts.

I will not cover in detail the issue of the overall number of people in these inpatient units (I went through this record of failure against the succession of targets the government set for itself recently here. 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 its successors 12 years on from Winterbourne View.  

These blogposts will focus on information produced publicly by NHS Digital/NHS England from one of two datasets. It uses data from 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 yearly blocks, and some of the information I report for every year 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 March 2023. 

In this post I have not used information from the Mental Health Services Dataset (MHSDS), 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 aspects of their activity to the MHSDS. According to NHS Digital (now absorbed into the NHS England empire) provider organisations contributing information have been subject to a cyber-attack which means that data from the MHSDS has not been complete for almost a year.

As with the previous series, these four blogposts will focus on:

• Who is going into inpatient services?
• How far are people from home, and 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 various iterations of the Transforming Care programme and its rebranded successors 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 seven different years (each one October to September), 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, pre-COVID, the overall number of admissions to inpatient services was increasing, from 1,810 admissions in 2015/16 to 2,250 admissions in 2018/19. The total number of admissions dropped to 1,745 admissions in Oct 2019 - Sept 2020, when COVID-19 hit, increased in 2020/21 to 1,830 admissions, then dropped again in 2021/22 to 1,530 admissions. In total, there have been 13,170 admissions to these inpatient units in the last sseven years - we don't know how many of these are the same people being admitted more than once or different people being admitted.

The second thing to notice is that a large proportion of admissions (the red chunk) are actually transfers from other hospitals (mainly other inpatient services of various types), running consistently at 20% or more of all admissions. The third thing I want to mention is that more than one in six admissions (the lilac chunk) are re-admissions, where people had previously been in an inpatient service less than a year before. Finally, the purple chunk shows that getting on for two thirds of admissions to inpatient services (63% in 2021/22) are people who have not been in an inpatient unit for at least a year (or maybe never).

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 five one-year blocks (starting in October 2016, through to September 2022).

In 2021/22, almost half of people (755 people; 49%) were admitted from their ‘usual place of residence’ and 43% of people (655 people) were admitted from other inpatient and/or hospital services. A further 75 people (5%) in 2021/22 were admitted from ‘penal establishments’ and 15 people (2%) were admitted from residential care services. In line with the overall decline in the number of admissions when comparing 2016/17 to 2021/22, the number of people being admitted from most types of place has also dropped. There are two exceptions: people being admitted from temporary places of residence (5 people in 2016/17; 20 people in 2021/22), and people being admitted from general hospitals/A&E wards (170 people in 2016/17; 295 people in 2021/22).

 

Overall, the number of people admitted to inpatient services have, with some fluctuations, been consistently lower since the COVID-19 pandemic started. However, there are signs that the promises of Building The Right Support in 2015 about effective community support for people have not been kept. The number of people being readmitted within a year of leaving hospital has hardly changed in six years, and the number of people being admitted from general hospitals/A&E wards in particular has risen sharply and stayed high. The AT dataset is also bad at recording people with learning disabilities and autistic people who are in general hospital mental health inpatient wards - the MHSDS is much better at including people in these circumstances but we don't have comprehensive national information from this dataset at the moment.

Have any changes in admissions resulted in changes to the legal status or the ward security of people with learning disabilities and autistic people in inpatient units? A persistent argument has been that people on MHA Part III sections (particularly those with legal restrictions) and people in higher security places are more likely to need to remain in inpatient services, so the number of people in these categories should not change much even if the number of people in inpatient units reduces overall. 

The graph below shows the number of people in inpatient units at the end of March each year from 2016 to 2023, broken down by the legal status of people in inpatient units according to Assuring Transformation data.

The most common legal status for people in inpatient units is a Part II section, where the number of people has dropped by 14% from 2016 to 1,135 people in March 2023. The next most common legal status is a Part III section with restrictions, where the number of people has dropped by 24% from 2016 to 545 people in March 2023. Less common are people with Part III sections without restrictions (which dropped by 46% from 2016 to 220 people in March 2023), people not subject to the Mental Health Act (which dropped by 38% from 2016 to 200 people in March 2023), and people in other sections (which dropped by 18% from 2016 to 45 people in March 2023). It is clear that reductions in the number of people in inpatient units have reduced for people with almost all types of legal status from 2016 to 2023.

The picture is similar when looking at ward security, as the graph below shows. The most common level of ward security is 'general', where the number of people in 'general' ward security dropped by 15% from 2016 to 1,145 people in March 2023. The next most common level of ward security is 'low secure', where the number of people dropped by 35% from 2016 to 550 people in March 2023. Together, people in 'general' and 'low secure' places were 79% of all people with learning disabilities and autistic people in inpatient units in March 2023. 

The number of people in medium secure inpatient units also dropped by 38% from 2016 to 320 people in March 2023, with smaller numbers of people recorded in high secure units (65 people) and Psychiatric Intensive Care Units (70 people - an increase of 56% from 2016).

Clearly, reducing the number of people in inpatient units does not need to exclude people on Part III sections or people on low or medium secure wards.

Since the start of the COVID-19 pandemic, it looks like consistently fewer people are being admitted to the kind of inpatient wards/units covered by AT, and that these reductions aren't confined to people with a particular legal status or wards with particular levels of security. There are real questions about the extent to which these figures suggest a lack of the kind of support outside hospitals that has been promised for over a decade. People are still being moved between inpatient units, and more people are coming into inpatient units from hospital A&E departments and temporary accommodation. We don't know whether more people with learning disabilities and autistic people are going in and out of general hospital mental health inpatients and what people's experiences are in these places. We also don't know how many people are getting any sort of support outside of hospital, and how good that support is. 

In the next blogpost I'll look at a couple of consequences of this - how far people from home are people being sent, and how long people are staying in these places.