Conclusions and Recommendations
1. The continued operation of large mental
health hospitals is incompatible with the Department's model of
care for people with learning disabilities and challenging behaviour.
Despite the agreed aim that people with learning disabilities
should live and receive care in the community, there has been
no closure programme for large mental health hospitals. The availability
of places in mental health hospitals has reduced the pressure
on local commissioners to revise their commissioning strategies
to expand the capacity and capability of local community services.
We were pleased to hear NHS England's commitment to a closure
programme for large NHS mental health hospitals, along with a
transition plan for the people with learning disabilities within
these hospitals, from 2016-17. All the witnesses recognised that
a closure programme required careful planning, management and
consultation with all relevant stakeholders, and the expansion
of community services before people with learning disabilities
and challenging behaviour were discharged and hospitals closed.
It is, therefore, vital that the proposed closure programme for
mental health hospitals is matched by the necessary growth in
high-quality community services. We look forward to receiving
details of the closure programme, and a transition plan, within
six months. Our recommendations below are designed to support
this transition.
2. It is a fundamental failing that the Department
currently lacks the data it needs to deliver its policy objectives
for people with learning disabilities.
Without an overall dataset on the population with learning disabilities
and challenging behaviour, the Department is unable to oversee
effectively a co-ordinated programme of care for people with learning
disabilities and challenging behaviour. There are currently two
separate measures for counting the number of people with learning
disabilities in mental health hospitals which give different figures
and which the Department cannot reconcile. The Department accepts
that its data on the number of people with learning disabilities
in mental health hospitals is not good enough. It believes the
quality of the data has improved since 2011-12, when its data
was "absolutely non-existent". It still lacks up-to-date
information and it does not collect data on those who are receiving
treatment services in community placements, those who are in prison,
those who have other contacts with the criminal justice system,
or those readmitted to hospital.
Recommendation: The Department should mandate
the timely collection of a consistent dataset on people with learning
disabilities and challenging behaviour, to inform effective planning
and management of their care, and to monitor their movements through
health services, social services, and the criminal justice system.
3. Current commissioning practice for people
with learning disabilities is not delivering the high-quality
community-based care envisioned by the Department in its model
of care. The old model was one of institutional
care. However this is no longer what NHS England, working with
the Care Quality Commission, will accept. Although there will
still be the need for some inpatient provision, the Department
and NHS England now consider the institutional model of care to
be completely inappropriate. The new model will have a much greater
focus on community services provision and building the capacity
in the community to support people, as well as preventing the
need for admission in the first place. NHS England needs a fundamental
redesign of the way that services are commissioned to move away
from institutional care. Local commissioners continue to place
people with learning disabilities in mental health hospitals.
Over a third of patients are in hospitals more than 50 kilometres
from their homes and too many people stay in hospital for too
long. A fifth of people in in-patient settings had been there
for more than five years. NHS England knows that many patients
and families want to be closer to home, cared for in the community
and supported to live as normal a life as possible. Delaying discharge
also has the effect of institutionalising people, making their
reintegration to the community more difficult.
Recommendation: NHS England should use its
commissioning framework to require local commissioners to comply
fully with the Department's stated aim to promote community based
services rather than hospital admissions for people with learning
disabilities.
Recommendation: The Department should set
out the responsibilities on local health and social care commissioners
to put in place commissioning strategies which ensure an adequate
provision of the range of community services and housing required
by people with learning disabilities and challenging behaviour.
4. The lack of pooled health and social care
budgets exacerbates the inadequate levels of community services,
resulting in unnecessary admissions of people with learning disabilities
to mental health hospitals, and delays in their discharge back
to their community. Local commissioners
have not yet developed health, social and housing services of
good enough quality to meet the needs of people with learning
disabilities and challenging behaviour, if they are to be properly
supported in the community. Without this capacity in the community
there may often be no alternative to admission to a mental health
hospital. In Salford, often cited as a beacon of good practice,
a pooled budget supports integrated health and social care management,
with a team committed to keeping people out of mental health hospitals
by supporting them in the community. The Winterbourne View Concordat
set out a strong presumption in favour of the use of pooled budgets
to minimise health and social service overlaps and save money.
However only 27% of local areas have voluntarily pooled budgets.
This is why it is right that the NAO and Sir Stephen Bubb recommended
that pooled budgets should be mandated. The Department could do
so through the annual NHS Mandate, which would not be revised
for implementation until April 2016. This would require greater
joint planning and provision from local commissioners.
Recommendation: The Department should mandate
the use of pooled budgets for people with learning disabilities
and challenging behaviour from April 2016, to build improved community
services through joint working by local health and social care
commissioners.
5. Discharges are being delayed because funding
does not follow the patient. The NHS meets
the cost of most people with learning disabilities in mental health
hospitals. However the funding to meet a patient's cost of care
does not follow them when they are discharged from hospital. Local
commissioners face the cost of planning and commissioning bespoke
community services each person will require when discharged. This
financial disincentive results in delays to people's discharge
from hospital, while complex negotiations take place between NHS
England, clinical commissioning groups and local authorities,
to develop a joint-funding arrangement for a person's community
placement. Some local authorities' reluctance to accept and fund
individuals in the community will be exacerbated by current financial
constraints. Unlike previous moves to support care in the community,
there is no 'dowry-type' payment that goes with the individual
to support transfer to the community.
Recommendation: The Department should identify
how funding can follow the patient to meet the costs of new community
services to keep people out of hospital. It should also set out
the arrangements for its proposed 'dowry-type' payments to local
commissioners from NHS England to meet the costs of supporting
people discharged from hospital.
6. People with learning disabilities, and
their families, have too little influence on decisions affecting
their admission to mental health hospital, their treatment and
care and their discharge. We heard about
the importance of strengthening the rights of people with learning
disabilities and their families to challenge decisions made about
their treatment and care. Unfortunately, it is still too difficult
to challenge the decision by medical and mental health professionals
to Section a patient under the Mental Health Act, to challenge
a decision to admit the patient to a mental health hospital which
is a long way from their family, or to propose alternative treatment
and care arrangements. The Department and NHS England both accepted
the need for a more rights-based system. The Department said that,
because of the inequity in power between institutions and families
of people with a learning disability, the next step would be to
enshrine rights in law, and that this would be covered in a Green
Paper.
Recommendation: The Department should strengthen
the legal rights of people with learning disabilities and their
families, to enable them to challenge decisions on the location
and nature of their treatment and to ensure that they receive
advocacy support in doing so.
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