Long-stay hospitals for people with learning difficulties are being closed, while private providers queue up to fill the gap. Mark Hunter asks if the trend heralds a return to institutional care by the back door
At some point in the not-too-distant future a government minister will step forward to announce, with a great fanfare, that the last NHS long-stay hospital for people with learning difficulties has been closed.
After years of broken promises and missed deadlines, the final brutal reminders of the Victorian lunatic asylums will have been swept into history. Few will mourn the demise of the monolithic institutions that, for so long, were used to house, care for and often detain people with learning difficulties. However, many will be asking what exactly has happened to the vulnerable and marginalised people who once lived there?
The answer may lie in the recent growth of private sector provision for people with learning difficulties; or in the use of campus-style NHS hospitals; or in out-of-area placements which may be community-based, but sited so far from the placed person's friends and family that they become institutional in all but name.
According to latest figures there are still 10 NHS long-stay hospitals in operation. Between them they provide 239 beds for people with learning difficulties. This is a decrease from 752 beds in 2003 and reflects the government's ponderous progress towards its 2004 deadline (set in 2001's Valuing People report and later put back to 2006), by which all these long-stay hospitals were to have closed.
By contrast, the private sector is booming. The Healthcare Commission estimates there are now at least 40 private providers of accommodation for people with learning difficulties offering more than 1,000 beds.
Many of these providers offer services that are unashamedly hospital-based. Take, for instance, the glossy brochure produced by the St Luke's Hospital Group to advertise its range of "low secure facilities".
"St Luke's has been set up to confront an inconvenient and unavoidable reality," it states. "That is hospital care is essential for many people with learning disability and mental health needs but such hospital care needs delivered in a form consistent with the values of our age."
So, are people with learning difficulties simply being turfed out of one institution into another, so that the government can belatedly claim to have met its own target?
Certainly, the government seems to be aware of the danger. Care services minister Ivan Lewis recently launched a scathing attack on local authorities for commissioning services for people with learning difficulties from private providers in new purpose-built hospitals.
He told an all-party parliamentary group that the practice was unjustified, went against the principles of Valuing People and would not be allowed to continue.
"No adult with learning difficulties should be in hospital unless they are ill or a serious danger to themselves," he said.
The Healthcare Commission, whose investigation of Cornwall Partnership NHS Trust revealed widespread abuse of people with learning difficulties by staff at Budock Hospital near Falmouth and several other units, is also keen to emphasise that people leaving the NHS establishments should receive high quality care.
"It is very important that the standards of care for people with learning disabilities are met, regardless of whether that care is provided by the NHS or in the private sector," says the commission's learning disability lead, Fiona Ritchie.
To ensure that these standards are met, the commission recently launched an audit of health care services for people with learning difficulties that will cover the private and the public sector.
"As people are moving out of long-stay hospitals, it is important that they are moving into services with person-centred plans and that they are fully involved in decisions about re-provision," says Ritchie.
"The whole idea of closing long-stay hospitals is to ensure that people are offered a better quality of care and a more fulfilling life. That is why our audit of health care services for people with learning disabilities will cover both the public and the private sector and will check that standards are being met across the board."
However, many of those working with people with learning difficulties are deeply sceptical that such personalised care can be provided within a private hospital.
"The scale of operation just doesn't allow it," says James Churchill, chief executive of the Association for Real Change.
"Some [private hospitals] have up to 100 places. There has been copious research showing that this is a model that just doesn't work. Over time it's almost inevitable that the system leads to institutionalisation and in the worst cases abuse."
Churchill acknowledges that it can be difficult to provide community-based care for some people with learning difficulties. Many of those housed in long-stay hospitals have complex needs. They may have been sectioned under the Mental Health Act 1983, be at risk of offending or exhibit severely challenging behaviour.
Nevertheless, with specialised care offered on an individual basis, these needs can be met, says Churchill. Such care may not be cheap. But then, at £3,000 a week, nor is a placement at a private hospital.
Churchill is critical of local authorities and primary care trusts that fail to invest in local specialised resources for people with learning difficulties. With no local services available, it is inevitable that many people are placed far from their friends and family. Out-of-area placements also make it difficult for the commissioners to monitor the quality of care.
"The problem is that the need for these highly specialised services is relatively low so local authorities are reluctant to invest in something that they may not need for three or four years. There's a need for collaborative working.
"There's no doubt that some of these guys can be very difficult to care for," he says. "But they are not ill, so they should not be in a hospital."
This is a view echoed by Ayesha Janjua, policy and campaigns officer at the charity Turning Point. She points out that Turning Point has achieved considerable success in providing community-based services for people coming out of long-stay hospitals.
This includes people with some of the most challenging needs, including those with so-called "forensic" histories.
One such service is provided by Alfred Minto House in Nottingham which specialises in helping people with forensic histories make the transition from hospital and secure settings to a more independent life in the community. It provides a supportive environment, regular one-to-one sessions with key workers and an activities programme. Turning Point also provides a move-on service and an outreach service in the area.
"What is needed is individualised support given as independently as possible," says Janjua. "This means ensuring that the individual's needs remain at the centre of transition, with an appropriately tailored care package and effective re-provision of support services. Individuals should be allowed a measure of choice and control that is balanced with a risk assessment drawn up with the individual."
Janjua points out that, even after the last long-stay hospital has been closed, there will still be far too many unsuitable placements of people with learning difficulties.
"There has been an increase in the number of beds in the private sector," she says. "And these hospitals are getting bigger, which is a bit worrying. There are also a lot of out-of-area placements where there is no continuity of care and there are still a lot of people with learning difficulties in campus-style hospitals. So it doesn't end with the long-stay hospitals. There's still a lot more to be done."
Hospitals' history1913: People with a learning difficulty are detained in long-stay institutions under the Mental Deficiency Act. 1957: Royal commission recommends that segregation of people with a learning difficulty should end. 1971: Better Services for the Mentally Handicapped white paper begins moving people out of long-stay hospitals into the community. 1990: NHS and Community Care Act recognises the right of people with a learning difficulty to an assessment for community care services. 2001: Valuing People white paper sets targets to move people out of long-stay hospitals to the community by April 2004. 2003: Government admits that it will not meet the target and that it will be 2006 before some hospitals finally close. 2006: There are still 239 people with learning difficulties in 10 NHS long-stay hospitals.
Valuing People Support Team
The Healthcare Commission
Association for Real Change