winterbourne 180x120The institutional model of care for people with learning disabilities is “completely inappropriate” and a redesign of the system is needed to ensure they can live in the community, a Commons committee has concluded.

The Public Accounts Committee (PAC) said the continued operation of large mental health hospitals is incompatible with the Department’s model of care for people with learning disabilities and challenging behaviour. It also noted that despite the agreed aim that people with learning disabilities should live and receive care in the community, there has been no closure programme for large mental health hospitals. 

In addition, the PAC said the availability of places in mental health hospitals has reduced the pressure on local commissioners to revise their commissioning strategies to expand the capacity and capability of local community services. 

Redesign of way services are commissioned

The PAC also said that NHS England needs a fundamental redesign of the way that services are commissioned to move away from institutional care. More than a third of patients are in hospitals 50 kilometres or more from their homes, and a fifth of people in in-patient settings had been there for more than 5 years. Delaying discharge also has the effect of institutionalising people, making their reintegration to the community more difficult.

It recommended that NHS England use its commissioning framework to require local commissioners to comply fully with the Department of Health’s stated aim to promote community-based services rather than hospital admissions for people with learning disabilities.

In addition, the PAC recommended that the Department of Health should set out the responsibilities on local health and social care commissioners to put in place commissioning strategies which ensure an adequate provision of the range of community services and housing required by people with learning disabilities and challenging behaviour.

The Committee took evidence from a range of leaders in the sector: Sir Stephen Bubb, chief executive of ACEVO; David Congdon, advisor to the Challenging Behaviour Foundation and former head of campaigns and policy at Mencap; Vivien Cooper, chief executive of the Challenging Behaviour Foundation; Una O’Brien, permanent secretary, Department of Health; Jon Rouse, director general, social care, Local Government and Care Partnerships, Department of Health; Simon Stevens, chief executive of NHS England and Jane Cummings, chief nursing officer at NHS England.

“Badly let down”

In evidence to the PAC, NHS England acknowledged that it was “indefensible” to make so little progress towards the commitment to discharge people with learning disabilities, as a result of which, people had been “badly let down”.

PAC chair, Margaret Hodge MP, said it was “refreshing” that NHS England took responsibility for the lack of progress. She also welcomed NHS England’s commitment to develop a closure programme for large NHS mental health hospitals, along with a transition plan for the people with learning disabilities within these hospitals, from 2016-17.

“It is vital that the closure programme is matched by the necessary growth in high-quality community services,” Hodge warned. “However, local commissioners have so far failed to deliver the high quality community-based care envisioned by the Department.”

The PAC acknowledged the evidence they received that careful planning, management and consultation with all relevant stakeholders, and the expansion of community services was required before people with learning disabilities and challenging behaviour were discharged and hospitals closed. It is, therefore, vital that the proposed closure programme for mental health hospitals is matched by the necessary growth in high-quality community services, they said. “We look forward to receiving details of the closure programme, and a transition plan, within six months.”

Pooled budgets

This lack of progress is linked to funding, which Hodge acknowledged and called for change. “The Winterbourne View Concordat set out a strong presumption in favour of the use of pooled budgets to minimise overlaps between health and social services and save money. However only 27% of local areas have voluntarily pooled budgets. The Department should mandate the use of pooled budgets from April 2016.

“Discharges from hospital are being delayed because funding does not follow the individual when they are discharged into the community. This acts as a financial disincentive for local commissioners who have to bear the costs and responsibility for planning and commissioning community services. Delaying discharge has the effect of institutionalising people, making their reintegration into the community more difficult.

“Some local authorities’ reluctance to accept and fund individuals in the community will be exacerbated by current financial constraints. The Department should set out its proposals for 'dowry-type' payments from NHS England to meet the costs of supporting people discharged from hospital.”

The PAC also noted that proper consideration must, therefore, be given not just to building capacity in the community, but also to enshrining in law patients’, and their families’, right to challenge the decisions taken, whether they are about treatment, admission to mental health hospital, or community care services provided.

In conclusion, Hodge said it is essential that the redesign of the system puts people with learning disabilities at the heart. “Proper consideration must, therefore, be given not just to building capacity in the community, but also to enshrining in law patients’, and their families’, right to challenge the decisions taken, whether they are about treatment, admission to mental health hospital, or community care services provided – and ensuring they receive the advocacy support to enable them to do so."

Welcome report

In response, in a joint statement, Jan Tregelles, chief executive of Mencap, and Viv Cooper, chief executive of the Challenging Behaviour Foundation, said:

“We welcome the Committee's report and recommendations, which highlight the key elements required to see progress on the delivery of meaningful change promised to people with a learning disability and their families over 3 years ago. 

"In particular we look forward to seeing and being involved in the development of the closure programme Simon Stevens announced to the Committee, and welcome the news of additional 'dowry' funding he outlined to help get people out of inpatient settings. 

"The Committee also makes important recommendations on the urgent need for NHS England to force local commissioners to develop new community services and for the Department of Health to mandate NHS England to develop pooled budgets between health and social care.

"Individuals must be empowered through funding that follows them when they are discharged into the community. This will remove disincentives for local commissioners so they develop the support, services and housing needed for people to move out of in-patient settings and return to their communities."