Select Committee on Health Memoranda

3.  NHS RESOURCES AND ACTIVITY

3.5  Care of Mental Health and Learning Disability Patients

  3.5.1  Could the Department update the information given in Tables 3.5.1(a) to (d), 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? [3.5.1]

CARE OF PATIENTS UNDER LEARNING DISABILITY AND MENTAL ILLNESS SPECIALITIES

  1.  The estimated number of in-patients under the care of the learning disability speciality, at the end of each year, fell to 5,350 in 2001-02 from 19,600 in 1991-92—Table 3.5.1(a). This is mainly due to the fall in the number of very long stay patients, from 13,600 to 2,400 over the period. 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 31,350 in 2001-02 from 45,100 in 1991-92—Table 3.5.1(b). This reflects a reduction in dependence on long stay hospital beds and growth in provision of alternative forms of supported residential and home based services and community teams.

  2.  There has been a substantial increase in the number of patients with learning disability discharged from hospital after a short stay. Table 3.5.1(c) shows that 77% of patients in 2001-02 had been in hospital for less than a week. This compares with 65% of those in 1990-91; this probably reflects the increased provision of respite care.

  3.  Table 3.5.1(d) shows a decrease in the number of in-patient episodes of Mental Illness care lasting less than one month. There were 110,700 discharges in 2001-02 after short stay episodes (62% of all discharges) compared with 125,300 in 1990-91 (64% of all discharges).

  4.  Table 3.5.1(e) 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% in 2001-02). This compares with an estimated 87% for mental illness patients in the same year, Table 3.5.1(f).

  5.  In the case of learning disability, patients aged 65 or over, 73% return to their usual place of residence with a further 21% transferred to other NHS providers. This compares to 69% and 14% respectively for mental illness patients.

  6.  Of the learning disability patients under 65 discharged after a stay of a year or more (an estimated 740 in 2001-02), 39% returned to their usual place of residence, 42% transferred to another NHS provider and 17% to local authority homes or other non-NHS institutions. For discharged mental illness patients (an estimated 2,040 in 2001-02), 48% returned to their usual place of residence, 26% transferred to another NHS provider and 13% to local authority homes or other non-NHS institutions.

  7.  Only an estimated 100 learning disability patients aged 65 or over were discharged after a stay of a year or more in 2001-02, compared with 790 for mental illness patients; the estimates of destination on discharge are based on small numbers and are unlikely to be reliable.

  8.  Table 3.5.1(g) shows that, in NHS facilities, the average daily number of beds on wards for patients with learning disabilities has fallen to 9,100 in 2001-02 from 21,400 in 1991-92. There has been a fall in the average daily number of beds available for mentally ill patients in NHS facilities to 34,000 in 2001-02 from 50,300 in 1991-92 Table 3.5.1(h). The number of long stay adult beds in learning disability wards has fallen to 3,600 in 2001-02 from 20,100 in 1991-92 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 31% of the number in 1991-92 with only a slight drop in the number of short stay beds.

  9.  In private nursing homes the number of learning disabilities beds for adults has risen by about two-thirds from 2,200 1991-92 to 3,700 beds in 2000-01. In staffed residential care (excluding small homes), the number of beds for adults has increased by 34% over the same period to 43,600 in 2000-01. Residential places for children decreased to 1,500 in March 2001 from 2,100 in March 1992.

  10.  The number of mental illness beds in private nursing homes and hospitals increased to 28,800 in 2000-01 from 12,700 in 1991-92. Most of the increase was in places for elderly patients.

  11.  Later information on places in care homes, private hospitals and clinics is not available. Following the establishment of the National Care Standards Commission (NCSC) on 1 April 2002 the routine statistical collections carried out by the Department of Health were discontinued. In future this information will be provided from the NCSC database to the Department. Due to operational and technical problems with the NCSC database they have not yet been able to provide the Department with the relevant information as planned.

NUMBER OF REPEAT DISCHARGES IN TABLES 3.5.1

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

  13.  The Department does however use, two indicators, compiled by the Commission for Health Improvement (CHI), reflecting the number of emergency psychiatric re-admissions. One, emergency psychiatric re-admissions for patients aged 17-64 re-admitted as an emergency to the care of a psychiatric specialist within 28 days of discharge, the other for people aged over 65. The re-admission indicator, for the calendar year 2002, covers patients under a consultant whose specialty is Mental Illness or Old Age Psychiatry and is based on HES data. But it excludes any patients with a primary diagnosis of drug dependency, alcohol dependency or eating disorder, (ICD 10 codes: F10 to F19, F50, Z502 and Z503). For these excluded conditions, re-admission is often considered a necessary part of the care. It should also be noted that any planned re-admissions are excluded from the count of re-admissions.

  14.  It is very important to note that the definition and coverage of this indicator differs from that applied to psychiatric discharges in Tables 3.5.1(c) and 3.5.1(d).

  15.  In 2002 the number of emergency re-admissions in England was 7,619 compared to 81,002 live discharges in the first 11 months of 2002, of the type covered—as described above. This implies a 28 day emergency re-admission rate of 9.41%.

  16.  The measure used by CHI looks at psychiatric re-admissions within 28 days using HES as the source. The measure used to assess delivery of the PSA target was psychiatric re-admissions within 90 days (adult 16 to 64) and the source was SAFFR, hence comparisons between the two sets of figures is therefore not appropriate.

Table 3.5.1(a)

PATIENTS UNDER THE CARE OF A LEARNING DISABILITIES CONSULTANT AT 31 MARCH BY DURATION OF STAY, ENGLAND: 1992, 1996 TO 2002 (2)

England Estimated numbers and rates per 100,000 population

Duration of stay	1992	1996	1997 (1)	1998	1999	2000	2001	2002
Number of patients All Durations	19,600	10,500	—	8,400	7,100	6,050	6,500	5,350
Under 1 year	2,800	2,000	—	1,900	1,950	1,350	1,500	1,450
1 to 2 years	1,100	1,100	—	800	650	700	600	550
2 to 3 years	800	600	—	650	500	550	600	400
3 to 5 years	1,300	900	—	700	900	750	750	600
5 years and over	13,600	6,000	—	4,400	3,100	2,700	3,100	2,400
Rates per 100,000 population All Durations	41	22	—	17	15	12	13	11
Under 1 year	6	4	—	4	4	3	3	3
1 to 2 years	2	2	—	2	1	1	1	1
2 to 3 years	2	1	—	1	1	1	1	1
3 to 5 years	3	2	—	1	2	2	2	1
5 years and over	28	12	—	9	6	6	6	5

Footnotes:

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

2.  Figures for 1996 to 2002 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 3.5.1(b)

PATIENTS UNDER THE CARE OF A MENTAL ILLNESS CONSULTANT AT 31 MARCH BY DURATION OF STAY, ENGLAND: 1992, 1996 TO 2002 (2)

England Estimated numbers and rates per 100,000 population

Duration of stay	1992	1996	1997 (1)	1998	1999	2000	2001	2002
Number of patients All Durations	45,100	34,600	—	31,750	30,800	29,900	31,550	31,350
Under 1 year	25,500	22,500	—	23,500	22,900	21,200	22,750	23,200
1 to 2 years	4,200	3,000	—	2,700	2,750	3,400	2,750	2,900
2 to 3 years	2,900	2,500	—	1,450	1,500	1,600	1,850	1,300
3 to 5 years	4,400	2,400	—	1,750	1,600	1,550	2,150	1,800
5 years and over	8,200	4,100	—	2,350	2,050	2,150	2,000	2,150
Rates per 100,000 population All Durations	94	71	—	65	63	61	64	64
Under 1 year	53	46	—	48	47	43	46	47
1 to 2 years	9	6	—	6	6	7	6	6
2 to 3 years	6	5	—	3	3	3	4	3
3 to 5 years	9	5	—	4	3	3	4	4
5 years and over	17	8	—	5	4	4	4	4
Footnotes: 1.Figures for 1997 are not available. Required data not collected from Trusts. 2.Figures for 1996 to 2002 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 3.5.1(c)

ESTIMATED DISCHARGES OF LEARNING DISABLILITES PATIENTS FROM NHS FACILITIES BY DURATION OF STAY 1990-91 AND 1995-96 TO 2001-02(1)

England Numbers and percentages

Duration of stay	1990-91	1995-96	1996-97	1997-98	1998-99	1999-2000	2000-01(2)	2001-02(2)
All durations	50,350	53,680	54,910	56,390	49,710	38,550	34,420	32,900
Under 1week	32,940	39,940	40,800	42,100	33,590	28,670	25,710	25,240
1 week	12,230	10,190	9,820	10,570	9,150	7,530	6,350	5,660
1 month	1,250	1,010	1,190	1,180	890	790	640	610
3 months	660	760	940	440	740	620	600	550
1 year	240	340	310	400	280	230	260	190
2 years	510	440	430	390	360	230	350	230
5 years	290	140	230	400	200	190	240	170
10 years +	2,220	820	1,150	760	510	250	270	250
Duration unknown	10	60	40	160	3,990	40	10	—
Percentages(3)
All durations	100	100	100	100	100	100	100	100
Under 1 week	65	74	74	75	68	74	75	77
1 week	24	19	18	19	18	20	18	17
1 month	2	2	2	2	2	2	2	2
3 months	1	1	2	1	1	2	2	2
1 year	0	1	1	1	1	1	1	1
2 years	1	1	1	1	1	1	1	1
5 years	1	0	0	1	0	0	1	1
10 years +	4	2	2	1	1	1	1	1
Duration unknown	0	0	0	0	8	0	0	0

Source: HES

Footnotes:

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

2.  Estimates for 2000-01 and 2001-02 are provisional due to temporary technical difficulties with the HES system.

3.  Percentages have been calculated using unrounded figures.

4.  The base year has not been updated to 1991-92 because reliable and consistent data are not available from the HES system.

Table 3.5.1(d)

ESTIMATED DISCHARGES OF MENTAL ILLNESS PATIENTS FROM NHS FACILITIES BY DURATION OF STAY 1990-91 AND 1995-96 TO 2001-02(1)

England Numbers and percentages

Duration of stay	1990-91	1995-96	1996-97	1997-98	1998-99	1999-2000	2000-01(2)	2001-02(2)
All durations	195,790	214,100	216,870	218,900	209,580	200,900	184,420	179,770
Under 1 week	38,890	46,350	48,300	47,500	47,250	45,640	41,380	40,940
1 week—	86,440	93,970	93,740	92,040	86,810	82,230	72,980	69,800
1 month—	48,980	51,820	52,890	54,500	51,250	50,500	46,780	45,960
3 months—	16,110	17,050	18,920	14,860	20,060	19,400	19,320	20,200
1 year—	1,780	1,560	1,590	5,490	1,820	1,770	2,130	1,680
2 years—	1,370	960	900	1,830	1,000	940	1,250	820
5 years—	630	290	220	830	260	240	360	220
10 years +	1,560	510	280	430	170	110	110	120
Duration Unknown	30	1,590	40	1,430	960	170	110	30
Percentages(3)
All durations	100	100	100	100	100	100	100	100
Under 1 week—	20	22	22	22	23	23	22	23
1 week—	44	44	43	42	41	41	40	39
1 month—	25	24	24	25	24	25	25	26
3 months—	8	8	9	7	10	10	10	11
1 year—	1	1	1	3	1	1	1	1
2 years—	1	0	0	3	0	0	1	0
5 years—	0	0	0	0	0	0	0	0
10 years+	1	0	0	0	0	0	0	0
Duration Unknown	0	1	0	1	0	0	0	0

Source: HES

Footnotes:

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

2.  Estimates for 2000-01 and 2001-02 are provisional due to temporary technical difficulties with the HES system.

3.  Percentages have been calculated using unrounded figures.

4.  The base year has not been updated to 1991-92 because reliable and consistent data are not available from the HES system.

Table 3.5.1(e)

ESTIMATED DISCHARGES OF LEARNING DISABILITY PATIENTS FROM NHS FACILITIES BY AGE, LENGTH OF STAY AND DESTINATION 1995-96 AND 2001-02

England Number and percentages	1995-96		2001-02(1)
Intended discharge destination	Length of stay less than one year	Length of stay of one year or more	Length of stay less than one year	Length of stay of one year or more
Aged under 65
Number of Discharges(2)	51,170	1,420	31,830	740
Percentage(3)
Usual Residence(4)	98	33	98	39
Temporary Residence	0	1	0	2
Other NHS provider(5)	1	36	1	42
LA residential	0	8	0	2
Non NHS institution(6)	0	15	0	15
Other and not known(7)	1	7	0	1
Aged 65 or over
Number of Discharges(2)	630	320	190	100
Percentage(3)
Usual Residence(4)	68	28	73	32
Temporary Residence	2	0	1	1
Other NHS provider(5)	17	38	21	48
LA residential	3	9	1	2
Non NHS institution(6)	5	22	3	14
Other and not known(7)	8	6	3	3

Source: HES

Footnotes:

1.  Estimates for 2001-02 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 3.5.1(f)

ESTIMATED DISCHARGES OF LEARNING DISABILITY PATIENTS FROM NHS FACILITIES BY AGE, LENGTH OF STAY AND DESTINATION 1995-96 AND 2001-02

England Number and percentages	1995-96		2001-02(1)
Intended discharge destination	Length of stay less than one year	Length of stay of one year or more	Length of stay less than one year	Length of stay of one year or more
Aged under 65
Number of Discharges(2)	136,530	1,900	125,410	2,040
Percentage(3)
Usual Residence(4)	87	45	87	48
Temporary Residence	3	6	3	9
Other NHS provider(5)	6	20	6	26
LA residential	0	8	0	4
Non NHS institution(6)	1	10	1	9
Other and not known(7)	3	11	1	3
Aged 65 or over
Number of Discharges(2)	71,920	1,400	50,780	790
Percentage(3)
Usual Residence(4)	76	24	69	21
Temporary Residence	2	4	2	3
Other NHS provider(5)	8	36	14	46
LA residential	2	12	2	4
Non NHS institution(6)	6	11	12	26
Other and not known(7)	5	13	1	1

Source: HES

Footnotes:

1.  Estimates for 2001-02 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 3.5.1(g)

HOSPITAL BEDS AND PLACES IN RESIDENTIAL AND NURSING CARE HOMES FOR PEOPLE WITH LEARNING DISABILITIES, ENGLAND: 1991-92, 1995-96 TO 2001-02

Numbers

	1991-92	1995-96	1996-97	1997-98	1998-99	1999-00	2000-01	2001-02
Average daily number of available beds in NHS facilities	21,380	12,680	13,040	12,280	11,530	10,600	10,020	9,090
For children short stay	150	220	290	280	270	290	280	210
long stay	240	150	110	100	100	90	100	70
For other secure units	.	330	420	440	420	400	430	410
short stay	880	1,630	1,350	1,440	1,420	1,340	1,320	1,370
long stay	20,110	10,350	7,440	5,940	5,280	4,720	4,190	3,640
Residential Facilities (1)	.	.	3,430	4,080	4,040	3,760	3,700	3,390
Beds in private nursing homes, hospitals and clinics (2)	2,330	3,320	3,360	3,580	3,850	3,840	3,770	..
Children	90	70	60	70	100	50	60	..
Other ages	2,240	3,250	3,300	3,510	3,750	3,790	3,710	..
Places in staffed residential homes for adults (2) (3)	32,550	38,180	40,500	41,580	42,610	44,130	43,580	..
Local authority	11,800	9,350	8,190	8,200	7,380	7,100	6,630	..
Voluntary	10,850	14,650	15,070	16,710	17,220	17,640	18,100	..
Private	9,900	14,190	17,230	16,670	18,010	19,390	18,850	..
Places in staffed residential homes for children (2) (3)	2,060	1,770	1,480	1,720	1,590	1,430	1,540	..
Local authority	1,600	1,240	950	1,070	1,040	800	890	..
Voluntary	330	430	310	290	260	310	330	..
Private	130	100	220	350	290	320	320	..
Places in small registered residential homes (<4 places) (2)	.	5,700	7,390	8,390	8,840	9,440	9,740	..
Voluntary	.	1,210	..	..	..	..	..	..
Private	.	4,490	..	..	..	..	..	..
Places in local authority unstaffed (group) homes (2)	2,900	2,650	2,990	..	..	..	..	..

Source: KO36, RAC5, RAC5(S), RAU1, KH03, RHN(A) and RA(Form A).

Footnotes:

1.  NHS residential facilities were recorded for the first time in 1996-97. Some of these beds may previously have been recorded under other headings.

2.  Data relate to 31 March.

3.  Excludes nursing care places in dual registered homes.

  . = not applicable, .. = not available.

Table 3.5.1(h)

HOSPITAL BEDS AND PLACES IN RESIDENTIAL AND NURSING CARE HOMES FOR PEOPLE WITH MENTAL ILLNESS, ENGLAND 1991-92, 1995-96 TO 2001-02

Numbers

	1991-92	1995-96	1996-97	1997-98	1998-99	1999-00	2000-01	2001-02
Average daily number of available beds in NHS facilities	50,280	39,480	38,780	37,880	37,060	35,470	35,490	33,980
For children short stay	580	470	430	400	420	390	410	400
long stay	100	110	110	120	120	100	120	90
For elderly short stay	5,860	6,390	7,370	7,380	7,290	7,350	7,620	7,550
long stay	14,710	9,330	8,230	7,410	6,990	6,040	5,540	5,250
For other ages secure units	880	1,370	1,580	1,920	1,750	1,880	1,950	1,850
short stay	15,720	15,080	14,500	14,460	14,420	14,120	14,380	13,800
long stay	12,430	6,730	5,410	4,910	4,710	4,310	4,200	3,850
Residential Facilities (2)	.	.	1,160	1,280	1,360	1,300	1,280	1,190
Beds in private nursing homes, hospitals and clinics (3) (4)	12,650	27,450	28,510	28,280	28,940	28,710	28,780	..
Children	80	90	60	100	50	10	70	..
Elderly	8,870	22,140	21,450	19,130	20,770	21,830	21,490	..
Other ages	3,710	5,210	6,990	9,050	8,120	6,870	7,210	..
Places in staffed residential homes for adults (1) (3) (5)	20,050	23,970	34,190	36,160	35,780	37,790	37,780	..
Local authority	5,560	4,690	4,910	4,530	3,480	4,120	3,910	..
Voluntary	4,250	5,560	7,270	7,070	6,280	6,770	6,720	..
Private	10,250	13,710	22,010	24,560	26,030	26,900	27,150	..
Places in small registered residential homes (<4 places)(3)	.	1,910	2,710	2,590	2,460	2,260	2,320	..
Voluntary	.	220	..	..	..	..	..	..
Private	.	1,700	..	..	..	..	..	..
Places in local authority unstaffed (group) homes (3)	2,000	1,660	1,840	..	..	..	..	..

Source: KO36, RAC5, RAC5(S), RAU1, KH03, RHN(A) and RA(Form A).

Footnotes:

1.  Discontinuity in data due to reclassification of some Elderly homes as homes for Elderly Mentally Ill patients.

2.  NHS residential facilities were recorded for the first time in 1996-97. Some of these beds may previously have been recorded under other headings.

3.  Data relate to 31 March.

4.  The method of data collection was changed in 1997-98 so the figures for 1997-98 are not strictly comparable with those for earlier years.

5.  Excludes nursing care places in dual registered homes.

  . = not applicable, .. = not available.

  3.5.2  Could the Department provide a table showing:

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

(ii)  umber 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? [3.5.2]

Number of People Sectioned by Trust and the type of section

  1.  Table 3.5.2(a) presents information on the number of admissions to NHS facilities (trusts, primary care trusts, mental health partnerships, and high security hospitals) where the patient was detained under the Mental Health Act 1983 at admission, and the number of occasions a patient already in hospital as an informal patient was placed under detention. Table 3.5.2(b) shows similar information for private mental nursing homes in each HA area (these data were forwarded to the Department via the National Care Standards Commission). There were a total of 24,600 formal admissions to NHS facilities in 2001-02 with a further 1,700 formal admissions to private facilities. Another 21,500 changes from informal to formal detentions were recorded (21,000 in the NHS and 500 in private facilities). There may be double counting of patients where a patient has been detained more than once in the year.

Number of people sectioned in proportion to HA population

  2.  It is not possible to produce reliable figures on the numbers of people sectioned by HA area of residence. The data provided on the aggregate return is provider based and does not collect geographic information on the area of residence. The Hospital Episode Statistics (HES) system does have some information on patients treated by area of residence, but the quality of data is poor on admissions of formally detained patients.

  3.  It is possible to look at the variation in the rate of psychiatric activity by health authority area of residence. Table 3.5.2(c) shows 2001-02 rate of consultant episodes varied from less than one to almost nine, per 1,000 with an average of almost five per 1,000 population. This does not imply similar variations in the rates for those sectioned.

Number of People Sectioned in Proportion to Admissions

  4.  In England, in 2001-02, there were 26,300 formal admissions to hospital (including high security hospitals and private hospitals) under the Act and a further 21,500 changes from informal status to detention where patients were already in hospital. A patient subject to more than one period of detention under the Act during the year will be counted in these figures each time they are admitted to hospital under detention or have a change from informal status while in hospital. It is therefore not possible to determine the number of people sectioned. Around 14% of all admissions [estimated as 178,100] under psychiatric specialities in NHS hospitals in 2001-02 were formal admissions [24,600].

---

---

Prepared 5 January 2004