House of Commons - Health

Select Committee on Health Memoranda

Memorandum by the Department of Health (Continued)

Could the Department provide a table showing, by service, net expenditure in real terms by central and local government on community care, broken down by residential and non-residential care (taking into account relevant service pay and price increases), over the most recent five year period for which such data are available? Could this data include Social Security and Housing expenditures contributing to Community Care objectives? Could it also show this data in graphical form?

1. Table 2.3.1 provides details of central and local government net expenditure on services for community care in England, for 1995-96 to 1999-2000, the latest year for which information is available. All figures have been adjusted to 1999-2000 prices using the latest Gross Domestic Product deflator. The reason for using the GDP deflator is that there is no single service pay and price index that would be appropriate for all sectors.

2. Community care expenditure is taken to mean expenditure on non-residential and residential care provided or arranged by local authorities for adults; community health services provided by the NHS for adults; certain social security benefits which support community care objectives; and certain expenditure on housing. Calculation of local authority expenditure by client group involves a degree of estimation.

3. The data in the table are set out in graphical form in Figure 2.3.1. The graph illustrates annual expenditure at constant prices since 1995-96, with the figures for 1995-96 indexed to 100. Department for Work and Pensions (DW&P) payments in support of community care, local authority expenditure on both non-residential care and residential care and expenditure on community health services have all grown significantly in real terms over the period. DW&P expenditure in support of residential care has declined as a direct result of the April 1993 community care reforms. These reforms transferred care management and funding responsibility for new admissions to independent sector care homes to local authorities and ended the former system of higher Income Support payments for people in such homes unless they had preserved rights. The number of preserved rights cases has declined substantially over this period. For admissions since April 1993 Income Support has been payable to people in independent sector care homes in broadly the same way as it is payable to people in their own homes. Expenditure on housing associated with community care fluctuated over the five-year period. On a comparable basis, expenditure on housing in 1999-2000 is some 20 per cent more in real terms than in 1995-96.

Table 2.3.1

NET EXPENDITURE ON SERVICES FOR COMMUNITY CARE (1999-2000 PRICES) ENGLAND

Footnotes:

Parts A and C

1. Local Authority expenditure is obtained from the RO3 current expenditure return.

2. Care assessment, management and administration, although included under local authority non-residential care in Part A, also includes expenditure which is relevant to residential care (Part C)

Part B

3. As it is not possible to supply net expenditure figures from the Hospital and Community Health Services (HCHS) programme budget, figures are gross expenditure and this may mean that they are slightly overstated.

4. For figures derived from HCHS programme budget analysis, it has been assumed that the following has been spent on adults: approximately 90 per cent of chiropody, 95 per cent of Family Planning, 1 per cent of Immunisation and Surveillance, 100 per cent of screening, 35 per cent of professional advice and support, 95 per cent of total general patient care, 95 per cent of community mental illness nursing, 80 per cent of community learning disability nursing, 70 per cent of Health Promotion and Services to GPs under open access and other community spending. It has also been assumed that 100 per cent of maternity care spent on the delivery and no costs are associated with the mother, and 100 per cent of community dental is spent on children.

5. The above allocations have been taken from the Expenditure per head of population exercise.

6. Administration costs for community health services are not separately identifiable and are not included in the Community Health figures.

7. Prior to 1996-97 monies provided for GP fundholders to purchase HCHS was exclusively allocated to General & Acute care. A more realistic allocation of expenditure shows that community services comprised a part of this expenditure. Hence figures for 1996-97, 1997-98 and 1998-99 are not directly comparable with previous years.

8. In 1996-97 several categories of the programme budget were affected by the changes to accounting practice and the changing structure of the NHS. Included in these was the need to capitalise redundancy payments and recharges were no longer included.

Part D and E

9. Source: Income Support Statistics Quarterly Enquiries May 1997—February 2000 inclusive. Based on a 5 per cent sample. Estimated Annual Income Support expenditure is based on caseload and average weekly payments in the enquiry week and is based on a four quarterly average.

10. Expenditure is based on Preserved Rights Residential Care & Nursing Home cases, and Residential Allowance cases for England.

11. Excludes unemployed claimants who are now provided for by Jobseeker's Allowance.

12. Based on Government Office Region.

13. Estimated Attendance Allowance and Disability Living Allowance figures are produced by apportioning out-turn figure for England by average payment, in week ending November 2000.

14. Disability Living Allowance replaced Attendance Allowance (for people under 65) in 1992.

15. Expenditure for Independent Living Fund estimated as 85 per cent of Great Britain out-turn as at November 2000.

Part F

16. The majority of new social housing (including that for elderly or disabled people) is now provided by Registered Social Landlords (RSLs) rather than local authorities. Source: DTLR P2 returns; data no longer collected after April 2001.

17. Source: Housing Investment Programme Annual Plan returns (section 5).

18. Disabled Facilities Grants are paid to the private sector, including RSL tenants, and also to LA tenants; figures shown represent totals of mandatory and discretionary grants under relevant Acts. Source: DETR P1D returns.

19. Housing Corporation ADP approvals for schemes by Registered Social Landlords (mostly housing associations) in respect of homes for rent and sale to certain "special needs" groups (frail elderly, people with mental health problems, learning, or physical disabilities) and one "general needs" group (elderly with warden support). This covers the Corporation's own programme and joint schemes, and also local authority-sponsored schemes using LA Social Housing Grant (LASHG). Source: Housing Corporation Stewardship Reports: elderly and disabled categories only.

2.4 CARE OF MENTAL HEALTH AND LEARNING DISABILITY PATIENTS

2.4a Could the Department update the information given in Tables 2.4, on patients under the care of a learning disability or mental illness consultant, discharges by length of stay, ages and destination, and residential and other places available? Could the Department identify the number of individuals concerned, and hence the number of repeat discharges?

2.4b Could the Department provide a table showing:

(i) number of people sectioned, by trust and by type of section?

(ii) number of people sectioned in proportion to HA population? If the data are not available, will the Department consider obtaining it from the HES?

(iii) number of people sectioned in proportion to number of admissions?

(iv) proportion of people who appeal against being sectioned and the outcomes of the appeals?

2.4c Could the Department provide a table showing, over the last four years, the numbers of people with mental health problems and with learning disabilities who have been in special hospitals, prisons and regional secure units?

INTRODUCTION

1. Tables 2.4.1, 2.4.3 and 2.4.5 present information on in-patients under the care of a learning disabilities specialist. Similar information for patients under the care of a mental illness specialist is given in tables 2.4.2, 2.4.4 and 2.4.6.

2. Tables 2.4.7 and 2.4.8 presents information on beds available in the NHS and private nursing facilities and places in residential care for people with learning disabilities.

3. Tables 2.4.1 to 2.4.6 are derived from the Hospital Episode Statistics (HES) system. The figures in tables 2.4.3 to 2.4.6 are estimates and provisional.

2.4 Care of Mental Health and Learning Disability Patients

CARE OF PATIENTS UNDER LEARNING DISABILITY AND MENTAL ILLNESS SPECIALTIES

4. The estimated number of in-patients under the care of the learning disability specialty, at the end of each year, fell to 6,100 in 2000 from 27,700 in 1990 (Table 2.4.1). This is mainly due to the fall in the number of very long stay patients, from 20,300 to 2,700 over the period. This fall in the number of very long stay patients resulted from the closure of long stay units and resettlement of patients in the community.

5. This is matched with a decrease in the number of in-patients under the care of mental illness specialists, at the end of the year, to 29,900 in 2000 from 56,200 in 1990. Again, this is due mainly to large falls in the number of long stay patients (Table 2.4.2).

6. There has been a substantial increase in the number of patients with learning disability discharged from hospital after a short stay. Table 2.4.3 shows that 74 per cent of patients had been in hospital for less than a week. This compares with 63 per cent of those in 1990; this probably reflects the increased provision of respite care.

7. Table 2.4.4 shows an increase in the number of short stay episodes of mental illness in-patient care; there were an estimated 122,800 discharges in 1999-2000 with a stay of under one month, compared to 121,300 discharges in 1990.

8. Table 2.4.5 shows that most learning disability patients under 65 discharged after a length of stay of less than a year return to their usual place of residence (98 per cent in 1999-2000). This compares with an estimated 88 per cent for mental illness patients in the same year (Table 2.4.6).

9. In the case of learning disability, patients aged 65 or over, 80 per cent return to their usual place of residence with a further 10 per cent transferred to other NHS trusts. This compares to 69 per cent and 10 per cent respectively for mental illness patients.

10. Of the learning disability patients under 65 discharged after a stay of a year or more (an estimated 760 in 1999-2000), 20 per cent returned to their usual place of residence, 45 per cent transferred to another NHS trust and 7 per cent to local authority homes or other non-NHS institutions. In comparison, of discharged mental illness patients (an estimated 2,170 in 1999-2000), 44 per cent returned to their usual place of residence, 28 per cent transferred to another NHS trust and only 4 per cent to local authority homes or other non-NHS institutions.

11. Only an estimated 80 learning disability patients aged 65 or over were discharged after a stay of a year or more in 1999-2000, compared with 1,500 for mental illness patients; the estimates of destination on discharge are based on small numbers and are unlikely to be reliable.

12. Table 2.4.7 shows that, in NHS facilities, the average daily number of beds on wards for patients with learning disabilities has fallen to 10,600 in 1999-2000 from 26,400 in 1989-90. There has been a fall in the average daily number of beds available for mentally ill patients in NHS facilities to 35,500 in 1999-2000 from 59,300 in 1989-90 (Table 2.4.8). The number of long stay adult beds in learning disability wards has fallen to 4,700 in 1999-2000 from 25,000 in 1989-90 with little change in the number of short stay beds. Similarly the number of long stay beds in mental illness wards has fallen to around a quarter of the number in 1989-90 with only a slight drop in the number of short stay beds.

13. In private nursing homes the number of learning disabilities beds for adults has increased almost three fold over the ten year period to 3,790 beds in 1999-2000. In staffed residential care (excluding small homes), the number of beds for adults has almost doubled in the ten-year period to 44,100 in 1999-2000. Residential places for children decreased to 1,500 in March 2000 from 2,100 in March 1990.

14. The number of mental illness beds in private nursing homes and hospitals increased to 28,700 in 1999-2000 from 7,700 in 1989-90. Most of the increase was in places for elderly patients. In addition, a change in the method of data collection in 1997-98 may also have had an effect on these figures.

NUMBER OF REPEAT DISCHARGES IN TABLES 2.4

15. The number of repeat discharges is not available. It is not possible to generate data on the number of times individual patients are discharged over a period of time after completing their spell in hospital.

16. The Department does however compile, as an indicator, the number of emergency psychiatric re-admissions. Emergency psychiatric re-admissions are defined as patients aged 16-64 re-admitted as an emergency to the care of a psychiatric specialist within 90 days of discharge. These include patients under the care of a consultant with Mental illness, Forensic Psychiatry and Psychotherapy specialties (codes: 710,712 and 713) excluding those with a primary diagnosis of drug dependency, alcohol dependency or eating disorder, (ICD 10 codes: F10 to F19, F50, Z502 and Z503). The re-admission method must be those counted as an emergency. It is important to note that the definition and coverage of this indicator differs from that applied to psychiatric discharges in Tables 2.4.3 and 2.4.4.

17. In 2000-01 the number of emergency re-admissions in England were 14,100 compared to 110,300 discharges in the same year (discharges are measured with the coverage described above for psychiatric re-admissions). This represents a re-admission rate of 13 per cent.

Table 2.4.1

PATIENTS UNDER THE CARE OF A LEARNING DISABILITIES CONSULTANT AT 31 MARCH BY DURATION OF STAY, ENGLAND : 1990, 1994 TO 2000 (2)

Footnotes:

1 Figures for 1997 are not available, trust level data not submitted for this exercise.

2 Figures for 1994 to 2000 have been estimated from the number of unfinished consultant episodes at 31 March. They are estimates based on returns to the Department from Trusts. These are not directly comparable with figures for earlier years, as the data from Hospital Episode Statistics is incomplete

Table 2.4.2

PATIENTS UNDER THE CARE OF A MENTAL ILLNESS CONSULTANT AT 31 MARCH BY DURATION OF STAY, ENGLAND : 1990, 1994 TO 2000 (2)

Footnotes:

1 Figures for 1997 are not available. Required data not collected from Trusts.

Table 2.4.3

ESTIMATED DISCHARGES OF LEARNING DISABILITIES PATIENTS FROM NHS FACILITIES BY DURATION OF STAY 1989-90 AND 1993-94 TO 1999-2000 (2)

Source: HES.

Footnotes:

1 Figures include transfers to other NHS providers. All durations include age unknown data.

2 Estimates for 1998-99 and 1999-2000 are provisional.

3 Percentages have been calculated using unrounded figures.

Table 2.4.4

ESTIMATED DISCHARGES OF MENTAL ILLNESS PATIENTS FROM NHS FACILITIES BY DURATION OF STAY 1989-90 AND 1993-94 TO 1999-2000 (1)

Source: HES.

Footnotes :

1 Figures include transfers to other NHS providers. All durations include age unknown data.

2 Estimates for 1998-99 and 1999-2000 are provisional.

3 Percentages have been calculated using unrounded figures.

Table 2.4.5

ESTIMATED DISCHARGES OF LEARNING DISABILITY PATIENTS FROM NHS FACILITIES BY AGE, LENGTH OF STAY AND DESTINATION 1993-94 AND 1999-2000

Source: HES.

Footnotes:

1 Estimates for 1999-2000 are provisional.

2 Age unknowns data are not included.

3 Percentages relate to intended discharge of patients as recorded inpatients' notes and are based on unrounded data.

4 Usual residence excludes the other categories listed in this table. It includes private dwellings whether owner occupied or rented and sheltered accommodation but not residential or nursing care. It includes patients with no fixed abode.

5 Other NHS Trust hospitals or NHS run nursing homes.

6 Independent residential or nursing care homes and private hospitals.

7 Prison, high security psychiatric hospitals, not known.

Table 2.4.6

ESTIMATED DISCHARGES OF MENTAL ILLNESS PATIENTS FROM NHS FACILITIES BY AGE, LENGTH OF STAY AND DESTINATION 1993-94 AND 1999-2000