Community learning disability and autism placements increasingly costlier than inpatient care – report

Government-commissioned study says new funding needed to support longstanding drive to discharge people with learning disabilities and autistic people from mental health hospitals, given current budget deficits

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Story updated 5 August 2022

Extra funding is needed to help people with learning disabilities and autistic people move out of mental health hospitals because of the increasingly greater cost of community-based care, a government-commissioned report has found.

The study, by consultants RedQuadrant, found the needs of those who were now being discharged were greater than previous cohorts, meaning commissioners were less likely to make savings on inpatient costs by discharging them.

The Department of Health and Social Care (DHSC), which is considering the report’s findings, published it alongside an action plan to meet its target of halving the number of people with learning disabilities and autistic people in hospital by 2024 on 2015 levels, under the Building the Right Support (BtRS) programme.

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 uncovered at Winterbourne View hospital in 2011.
  • In 2012, when there were 3,400 inpatients in the settings, it set a target of eliminating inappropriate such placements by June 2014, in Transforming Care, its response to Winterbourne View.
  • However, this was missed, with figures showing there were 3,000 inpatients as of September 2014.
  • In 2015, the government, NHS and local authority leaders published Building the Right Support (BtRS)which set a target for regional transforming care partnerships (TCPs) of reducing by 35%-50% the use of inpatient provision over the subsequent three years through investment in community support.
  • This also did not happen and, in 2019, the NHS Long Term Plan set the current target of at least halving inpatient numbers on 2015 levels by 2023-24, on a like-for-like basis, allowing for population growth.
  • As of May 2022, there were 2,010 inpatients, down 30.7% on 2015, the DHSC said in its latest action plan.
  • Six out of the 42 integrated care systems (ICS) – partnerships of health and social care leaders who are now responsible for delivering the BtRS programme – have met the 2023-24 target so far.

Significantly reducing inpatient numbers so people can receive more appropriate care and support in the community has been a government ambition since abuse was uncovered 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 inpatient numbers – how money can be moved from NHS-financed inpatient settings to fund council-commissioned care and support in specialised housing requiring upfront investment.

‘Limited data’

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

“We believe that the limited ability to analyse financial data in this way to provide a national perspective is a significant barrier to the effective oversight and management of the BtRS programme overall,” said the report.

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

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

Community costs growing as needs rise

Stakeholders told the authors that, while those discharged under the BtRS scheme in previous years had lower-level needs, relative need was increasing, meaning community placement costs were increasingly outstripping those of inpatient services.

“Stakeholders consistently told us that a growing proportion of those still requiring to be discharged had high support needs, and that this is having an impact on their overall [NHS commissioning] budgets,” the report said.

It added: “We heard from councils that there is a lack of funding to expand community teams, and that there are budgetary challenges in funding community packages.

‘Significant disincentives to discharge’

“We have heard that budget deficits in relation to this programme are increasing and it would seem inevitable that unless actions are taken to address the shortfall between savings released and new placement costs, there could well be significant disincentives to secure discharges, particularly of 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-based care for people discharged from secure inpatient settings.

However, FTAs were replaced last year by pathway funds, the guidance on which states these should reflect the savings released from inpatient care.

The report said that, with community-based costs increasingly exceeding inpatient fees, this limit “could become an increasingly powerful disincentive” to discharge patients.

Also, pathway funds, like FTAs before them, do not apply to people in mainstream beds, who account for half of inpatients, and whose community-based care must be funded from local NHS commissioning and local authority budgets. This includes dedicated funding for BtRS, which in 2022-23 comprises £40m from the NHS Long Term Plan and £21m through a community discharge grant for local authorities.

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

Additional funding stream needed

Besides high placement costs, the report found that other barriers included the availability and cost of suitable accommodation, and access to capital to fund it, recruitment and retention of a skilled workforce for community-based providers and complexities around funding arrangements between councils and NHS commissioners.

The report added: “Some form of additional funding stream is likely to be required to ensure that the impact of the creation of significant deficits on local health and adult social care system budgets does not begin to act as a disincentive to discharge those with higher levels of need.”

In response to the study, the chairman of the Local Government Association’s community wellbeing board, David Fothergill, placed the issue against a context of councils and providers handling “a recruitment crisis and increasing funding gaps”, along with “unmet and under-met need”.

He added: “This means that the savings made on reduced usage of institutional care must flow through to councils to allow them to pay for supporting people to live in the community, alongside continued transition funding for any double running costs.”

Sean Duggan, chief executive of the NHS Confederation’s Mental Health Network, which represents mental health providers, highlighted the challenges of quick and safe discharges because of the lack of ring-fenced NHS funding and the fact that investment in community services did not count towards government targets for increasing mental health spending.

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 more people with learning disabilities and autism can be moved out of hospitals and placed into the most appropriate community settings for them.”

Social workers question report findings

However, the report’s findings were questioned by social workers and others involved in the British Association of Social Workers’ homes not hospitals campaign, which is designed to help practitioners prevent hospital admissions and support discharge for current inpatients.

Retired social worker and BASW member Alan Dean said: “The data in this report is by admission limited and incomplete. The focus on high costs is misleading. Evidence suggests that costs will reduce over time when a life free from abuse with good community-based support is established.”

On this point, the RedQuadrant report said it had found evidence of the costs of community placements reducing over time, because of people building their independence as the impact of having lived in institutional care for a long time diminishes.

However, Dean added: “The report is correct to highlight the local authority funding issues, which require further work. The homes not hospitals campaign group will be pushing the DHSC on this”

A DHSC spokesperson said: “In the Building the Right Support Action Plan, we have set out funding we are providing to strengthen community support, prevent avoidable admissions and support discharges.

“This includes a £40m investment from the NHS Long Term Plan to continue to improve capacity and £30m of funding to continue putting keyworkers in place for children and young people with the most complex needs.

“A £21m community discharge grant to local authorities will also help people with a learning disability and autistic people to be discharged appropriately.”


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