1.On the basis of a report by the Comptroller and Auditor General, we took evidence from the Department of Health (the Department), NHS England and the Association of Directors of Adult Social Services about local support for people with a learning disability. We also took evidence from charities who support and lobby for people with a learning disability: the Challenging Behaviour Foundation, Mencap and United Response. The latter two charities also provide support services to people with a learning disability.
2.In England there are 129,000 people with a learning disability who receive support from local authorities, 29,000 of whom live in residential care or nursing homes. Approximately 2,500 people with a learning disability are in mental health hospitals, some with secure facilities. These people are considered a danger to themselves or others and have behaviour that challenges services. The Department and NHS England are seeking to move people out of mental health hospitals into support in the community.
3.NHS England acknowledged that it had made slow progress in moving people out of mental health hospitals into the community from 2012 to 2015 and that the last time the Committee considered this issue had been a wake up call in terms of what it needed to do to bring about profound change. As a result, in 2015, the Department and NHS England launched the Transforming Care programme. This aims to reduce the number of beds in mental health hospitals for people with a learning disability by 35%–50% by 2019. The programme has created 48 local partnerships which are formed of social and health care organisations to deliver the programme at local level. Moving people out of mental health hospitals is a complex task, and efforts to do this date back to the 1980s. It needs all stakeholders to work together under strong leadership with elements such as housing and funding in place.
4.The Association of Directors of Adult Social Services told us that the Transforming Care Programme cannot be delivered successfully using a centralised approach and that there needs to be local engagement and local expertise, in part to deal with the differences in bed numbers at local level. We asked how engaged local authorities are in the Transforming Care Programme. The Association of Directors of Adult Social Services told us that it and the Local Government Association are represented on the programme delivery board and that local authorities are represented on each of the local Partnerships with some of the Partnerships led by Senior Responsible Owners from local authorities. However, the Association of Directors of Adult Social Services noted that there was variable engagement by local authorities which it felt was because of a lack of clarity and confidence about financial flows.
5.NHS England told us that it believed that there has been demonstrable progress in moving people into the community since our 2015 evidence session. There are signs of this progress. Partnerships have reduced the overall numbers of people in mental health hospitals by 11% from October 2015 to December 2016 as intended. NHS England told us that as of March 2017, Partnerships had discharged 12% of people (some 330) out of mental health hospitals. We also heard that Partnerships had made progress in reducing actual bed numbers, and that they had achieved the target of reducing beds by more than 136 in 2016–17. However, Partnerships need to reduce bed numbers by 900–1,300 by 2019 so there is still a long way to go. The Challenging Behaviour Foundation told us that NHS England is still commissioning beds in ‘old fashioned institutions’. This will add to the tally of beds to be closed and may also be contrary to its service model. NHS England acknowledges the scale of the challenge to reduce the number of beds but believe that it is on track to do so.
6.The Challenging Behaviour Foundation told us that everyone wants the Transforming Care Programme to work and there is a united desire to move people out of mental health hospitals. While the Foundation was positive about the Partnerships’ potential, it told us that it had not seen evidence that Transforming Care was working yet. We asked NHS England how confident it was of reducing bed numbers as planned by 2019. It agreed with the National Audit Office’s assessment that there had been a solid basis for the programme but acknowledged that there was a lot more work to do to put the programme on track. It affirmed its commitment to do so.
7.Managing the number of people who are admitted and discharged from mental health hospitals is key to reducing the number of beds. The number of people admitted needs to reduce while the number discharged into the community needs to increase. Care and treatment reviews are the main mechanism to get people out of mental health hospitals, as well as avoiding admissions. NHS England introduced these reviews in October 2014 as a way to prevent unnecessary admissions and move people out of mental health hospitals as quickly as appropriate. NHS England policy is that everyone with a learning disability in a mental health hospital has a review every six months.
8.These reviews are not working as they should and as of December 2016 only 39% of people had a review in the previous six months. NHS England told us of the progress it has made in reducing the proportion of people in mental health hospitals who have not had a review, reducing it from 47% in January 2016 to 27% in December 2016, and to 20.5% by February 2017. During our evidence session NHS England announced the publication of its refreshed care and treatment review policy. NHS England explained that as part of this refreshed policy it is considering more frequent reviews for children and fewer reviews for people who are under Ministry of Justice restrictions or in secure settings. NHS England acknowledged that it had ‘further to go’ with care and treatment reviews but felt that it had already made ‘substantial moves in the right direction’.
9.We are aware that there are concerns about who attends the reviews. The Royal College of Psychiatrists submitted evidence claiming most of the reviews do not include an independent clinician who is sufficiently senior or experienced and able to properly challenge the care that the person is currently receiving. We therefore challenged NHS England on how it can be sure that the right people attend reviews. NHS England explained that local areas commission and monitor reviews, and the policy sets out how they should be carried out and by whom. The policy refresh also assessed how NHS England could improve its evaluation of reviews.
10.Between £135 million and £150 million per year will need to be made available to pay for health and social care support in the community as more people leave mental health hospitals and live in the community. Unless money is released from mental health hospitals, this will be an unfunded pressure on local authorities. The previous Committee found there were problems in how money was moving with the patient from paying for support in mental health hospitals to paying for support in the community. In particular, it reported that the lack of pooled budgets was exacerbating inadequate levels of community services, resulting in unnecessary admissions of people to mental health hospitals and delays in their discharge back to the community. It found that only 27% of local areas had pooled budgets with local clinical commissioning groups and recommended that the Department should mandate pooled budgets between clinical commissioning groups and local authorities. It also recommended that the Department should 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.
11.In January 2017, NHS England agreed how so-called ‘dowry’ money will move within the NHS for patients who had been in specialised commissioning mental health hospitals for 5 years as of 1 April 2016. This agreement did not deal with how money will move from the NHS to local authorities, although NHS England told us that this shift is starting to happen. However, just £1 million has moved, out of an estimated £10.8 million that could have been moved for this type of patient. This is due in part to a time lag when trying to reduce the number of beds, caused by the type of contract where beds are commissioned as a block. There is less progress with pooled budgets as only one third of clinical commissioning groups have pooled their budgets with a local authority. The delays in moving money with the patient is being felt by families. The Challenging Behaviour Foundation told us that families did not see that money is moving to pay for their child’s support in the community.
12.NHS England has provided Partnerships with some short-term support of £30 million transformation funding over three years, and £100 million of capital over five years to help provide housing. The transformation funding was oversubscribed in the first year, with Partnerships submitting bids for some £80 million for just £8 million of funding available that year. Capital funding has largely been unspent: NHS England estimates that £9 million of the 20.4 million allocated to Partnerships in 2016–17 will not be spent during the year.
1 C&AG’s Report, Local support for people with a learning disability, Session 2016–17, HC 1053
2 Q1; , paras 2, 4, 3.3
3 Q77; , paras 11, 2.5, 3.14
4 Q78; , paras 12, 2.8
5 Qq39, 40; , paras 5, 15, 2.4, 3.4
6 Qq63, 78; , paras 2.7, 2.8
8 Q43, , paras 13, 3.29
12 Q99; , paras 12, 2.6
13 Q55; , paras 3.6, 3.9 and 3.10
14 , para 3.9
15 , figure 15
17 Qq74, 76
18 Qq74, 76
19 , paras 15, 3.14
20 Committee of Public Accounts, Fifty-first Report of Session 2014–15, Care Services for people with learning disabilities and challenging behaviour, HC 973
21 Qq46, 47, 54; , para 3.19
22 Qq35, 36
23 Q54; , paras 3.14, 3.16
24 , para 3.15
24 April 2017