People with learning disabilities and ‘challenging behaviour’ could be failed if commissioners make significant cuts to hospital beds for the group in response to the government’s Winterbourne View programme.
That was the warning from the Royal College of Psychiatrists (RCPsych) in a report yesterday on the provision of inpatient services for people with learning disabilities and additional mental health, behavioural or forensic problems.
The government’s programme to improve support for this group in the wake of Winterbourne View includes commitments for commissioners to review the needs of people with ‘challenging behaviour’ placed in NHS-funded inpatient beds, with all those inappropriately placed transferred to community settings by June 2014. Ministers believe this would reduce numbers in so-called assessment and treatment beds from about 1200 now to 300-400, with savings from reduced hospital use channelled into developing effective community services.
The RCPsych said that it fully supported the government’s objectives. The report said people should be treated in the least restrictive setting possible and that, where people were admitted to hospital, they should receive high-quality support focused on returning them to the community as soon as possible.
Risks to safety
However, it warned that cuts to inpatient provision, in the absence of “significantly improved community services”, could compromise the health and safety of many service users.
A survey found there were currently about 3954 inpatient learning disability beds in England: 2393 secure beds for people with forensic needs due to offending or high-risk behaviour; 814 acute admission beds in assessment and treatment units; 622 rehabilitation or continuing care beds for people who had “stepped down” from secure or acute units, and 125 in other specialised categories.
It said this total was an “appropriate number” and represented a “substantial reduction” on previous levels of bed numbers, which had been brought about by significant improvements to community learning disability services and better links with mental health services.
The report warned that attempts to make further cuts to assessment and treatment beds could lead to “many more patients [ending] up in far more restrictive forensic beds”.
Community services ‘must be effective’
“We are happy for bed numbers to be reducing if the community services are geared up to support people effectively,” said Dr Ian Hall, chair of the RCPsych’s faculty of psychiatry of intellectual disability. “What we don’t want is for people to be supported by community services that cannot meet their needs.”
He said there were particular challenges in supporting people who engaged in harmful sexual behaviour or other high-risk behaviour such as fire-setting. While there were examples of good community-based support for them, Hall added: “It depends on the level of risk and the investment that, usually, local authorities are prepared to put into it. Certainly, people will require constant supervision. There are also people for whom even the best community support is not tenable but we must work towards [providing community-based care] for everyone.”
The report also said the full range of inpatient settings should be available in all parts of the country, as far as possible, so that service users would not need to move far, and they should all be ratified as high-quality under one of the RCPsych’s accreditation schemes. It said inpatient care should be integrated with community learning disability services to improve continuity of care.
Responding to the report, Mencap’s national officer for profound and multiple learning disabilities, Beverley Dawkins, said the charity was clear that not all assessment and treatment units should close, so long as remaining provision was of good quality.
She added: “It’s very hard to determine how many of these [inpatient] services would really be needed if you got community care right, especially from childhood. The trouble is that at the moment there are being used as places of last resort, are becoming people’s homes and are being misused.”
‘Large hospitals will close’
“Most people with learning disabilities and mental health conditions will never need to use specialist inpatient services and as better community services are developed, we should see a further reduction in the need for hospital placements and the closure of large hospitals,” said a Department of Health spokesperson.
The RCPsych report also raises further questions over whether all people with ‘challenging behaviour’ in inpatient settings are being supported through the government’s Winterbourne View programme. Figures from NHS England issued this month found 1317 people had been registered as being in hospital settings by clinical commissioning groups (CCGs), and most had now had their needs reviewed with a view to supporting them to move into the community.
This is well short of the RCPsych’s 3954 figure, despite the fact that people in all types of bed should be covered by the Winterbourne View programme, including those in forensic settings. Mencap and fellow charity the Challenging Behaviour Foundation have already expressed concerns that hundreds of people are being excluded from the programme.
One reason for the difference in numbers is that secure beds are commissioned centrally by NHS England, not CCGs. NHS England is now looking to ensure that all such clients are covered by the programme and receive a review of their needs.