Community placements for learning disabilities and autism increasingly expensive than hospital care – report

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More funding is needed to help people with learning disabilities and people with autism leave mental health hospitals due to the rising cost of community care, according to a government-commissioned report.

The study, by consultants RedQuadrant, found the needs of those now discharged were greater than previous cohorts, meaning commissioners were less likely to save on hospital costs by releasing them .

The Department of Health and Social Care (DHSC), which is reviewing the report’s findings, released it alongside an action plan to achieve its goal of halving the number of people with learning disabilities and autistic people hospitalized by 2024 compared to 2015 levels, as part of the Building the right medium (BtRS) program.

Missed targets

  • It has been a government priority to tackle the placement of people with learning disabilities and autistic people in mental health hospitals since abuse was discovered at Winterbourne View Hospital in 2011.
  • In 2012, when there were 3,400 inpatients in facilities, he set a goal to eliminate these inappropriate placements by June 2014, by Transforming carehis response to Winterbourne View.
  • However, this was missed, with figures showing there were 3,000 patients in hospital in September 2014.
  • In 2015, government, NHS and local authority leaders published Build the right medium (BtRS), which set a goal for Regional Care Transformation Partnerships (TCPs) to reduce hospitalization use by 35-50% over the next three years through investment in community support.
  • That didn’t happen either, and in 2019 the NHS long term plan set the current target of at least halving the number of hospitalized patients from 2015 levels by 2023-24, on a like-for-like basis, allowing for population growth.
  • In May 2022, there were 2,010 hospitalized patients, down 30.7% from 2015, the DHSC said in its latest action plan.
  • Six of 42 Integrated Care Systems (ICS) – partnerships of health and social service leaders who are now responsible for delivering the BtRS program – have met the 2023-24 target so far.

Drastically reducing the number of hospital patients so that people can receive more appropriate care and support in the community has been an ambition of the government since abuse was discovered at Winterbourne View Hospital in 2011, but successive targets have been missed (see box above).

The RedQuadrant report was designed to investigate a key challenge in reducing hospital inpatient numbers – how money can be transferred from NHS-funded hospital facilities to fund council-commissioned care and support in specialist accommodation requiring an initial investment.

“Limited Data”

It found that information on funding flows was limited, with national NHS and local authority datasets not recording specific spending on the BtRS.

“We believe that the limited ability to analyze financial data in this way to provide a national perspective is a significant impediment to effectively monitoring and managing the BtRS program as a whole,” the report states.

Drawing on financial information from five transformative care partnerships, it found that average community placement costs ranged from £133,013 to £185,271 per year, when high-cost placements were excluded. This compares to between £180,310 and £259,515 for specialist beds for learning disabilities or autism in secure hospitals commissioned by NHS England.

However, two of the 66 community placements cost around eight times that of an inpatient bed per year (£1.6m and £1.9m).

Community costs increase as needs increase

Stakeholders told the authors that while people who exited the BtRS program in previous years had lower-level needs, relative needs were increasing, meaning that community placement costs increasingly outpaced those of hospital services. .

“Stakeholders have consistently told us that an increasing proportion of those yet to be discharged have high support needs, and this is impacting their overall situation. [NHS commissioning] budgets.

“We have heard from councils that there is a lack of funding to expand community teams and that there are budget challenges in funding community packages.

“Important deterrents to discharge”

“We have heard that budget deficits related to this program are increasing and it would seem inevitable that unless steps are taken to close the gap between the savings generated and the new investment costs, there may well be disincentives important in obtaining releases, especially from those with the highest support needs.

The government had provided dedicated funding – known as Funding Transfer Agreements (FTAs) worth £180,000 per patient up to a cap – to fund community care for people discharged from hospital settings secured.

However, FTAs ​​have been replaced by pathway funds, with the guidelines saying these should reflect savings from hospital care.

The report says that, with community costs increasingly exceeding hospitalization costs, this limit “could become increasingly
a powerful deterrent effect” to get patients out.

In addition, pathway funds, like FTAs ​​before them, do not apply to people in ordinary beds, who make up half of hospital patients, and whose community care must be funded by the local NHS commissioning. and local authority budgets. This includes dedicated funding for the BtRS, which in 2022-23 includes £40m from the NHS long-term plan and £21m through a community discharge grant for local authorities.

However, the report highlighted that these funds were not ring-fenced, while a survey of councils for the report found that a quarter could only fund community packages for up to two-thirds of people ready to be released.

Additional funding stream needed

In addition to high placement costs, the report found that other barriers included the availability and cost of suitable housing, and access to capital to finance it, recruitment and retention of a workforce. skilled work for community providers and the complexity of funding arrangements between boards and NHS commissioners. .

The report adds: “Some form of additional funding stream will likely be required to ensure that the impact of creating large deficits on local budgets for adult health and social care systems does not
do not begin to deter firing those with higher levels of need.

In response to the study, Local Government Association Community Welfare Council Chairman David Fothergill placed the issue in the context of councils and providers dealing with “a recruitment crisis and growing funding shortfalls. “, as well as “unmet and under-met needs”. ”.

He added: “This means savings from reduced use of institutional care must be passed on to councils to enable them to pay to help people live in the community, alongside ongoing transition funding for any double cost of functioning.

Sean Duggan, chief executive of the NHS Confederation Mental Health Network, which represents mental health providers, highlighted the challenges of fast and safe discharges due to a lack of earmarked NHS funding and the fact that investment in community services did not matter to the government. targets for increasing mental health spending.

“Urgent need” for increased funding and workforce strategy

Echoing the findings of the RedQuadrant report, he added: “We urgently need the government to produce a fully funded workforce strategy and provide additional funding for these services so that more people with disabilities learning and autism can be moved out of hospitals and placed in the most appropriate community settings for them.

A DHSC spokesperson said: “In the Building the Right Support action plan, we have defined the funding we provide to build community support, prevent avoidable admissions and support discharges.

“This includes an investment of £40m from the NHS long-term plan to continue to improve capacity and funding of £30m to continue to put in place key workers for children and young people with disabilities. the most complex needs.

“A £21million community discharge grant to local authorities will also help people with learning disabilities and people with autism to be discharged appropriately.”