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The impact of transforming care on the care and safety of patients with intellectual disabilities and forensic needs

  • John L. Taylor (a1), Iain McKinnon (a2), Ian Thorpe (a3) and Bruce T. Gillmer (a3)
Summary

NHS England recently published a national plan to develop community services for people with intellectual disabilities and autism who display challenging behaviour by using resources from the closure of a large number of hospital beds. An ambitious timescale has been set to implement this plan. The bed closure programme is moving ahead rapidly, but there has been little progress in developing community services to support it. This paper discusses the impact of the gap between policy and practice on the care and safety of patients with intellectual disabilities and forensic needs who form a distinct subgroup of the target population and are being disproportionately affected by this government policy.

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Copyright
This is an open-access article published by the Royal College of Psychiatrists and distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Corresponding author
Correspondence to John L. Taylor (john2.taylor@northumbria.ac.uk)
Footnotes
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Declaration of interest

All authors are employed by Northumberland, Tyne and Wear NHS Foundation Trust. The opinions expressed are the authors' own and do not reflect the views of the Trust.

Footnotes
References
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1 NHS England. Building the Right Support. NHS England, 2015 (https://www.england.nhs.uk/wp-content/uploads/2015/10/ld-nat-imp-plan-oct15.pdf).
2 Department of Health. Transforming Care: A National Response to Winterbourne View Hospital. Department of Health, 2012.
3 Department of Health. DH Winterbourne View Review. Concordat: A Programme of Action. Department of Health, 2012 (https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213217/Concordat.pdf).
5 Public Accounts Committee. Oral Evidence: Care Services for People with Learning Disabilities and Challenging Behaviour (HC 973, Monday 9 February). Public Accounts Committee, 2015 (http://data.parliament.uk/writtenevidence/committeeevidence.svc/evidencedocument/public-accounts-committee/care-for-people-with-learning-disabilities/oral/18031.pdf).
6 Hogue, TE, Steptoe, L, Taylor, JL, Lindsay, WR, Mooney, P, Pinkney, L, et al. A comparison of offenders with intellectual disabilities across three levels of security. Crim Behav Ment Health 2006; 16: 1328.
7 Alexander, RT, Hiremath, A, Chester, V, Green, FN, Gunaratna, IJ, Hoare, S. Evaluation of treatment outcomes from a medium secure unit for people with intellectual disability. Adv Ment Health Intell Disabil 2011; 5: 2232.
8 Taylor, JL, Novaco, RW. A brief screening instrument for emotionally unstable and dissocial personality disorder in male offenders with intellectual disabilities. Res Develop Disabil 2013; 34: 546–53.
9 O'Brien, G, Taylor, JL, Lindsay, WR, Holland, AJ, Carson, D, Price, K, et al. A multicentre study of adults with learning disabilities referred to services for antisocial or offending behaviour: demographic, individual, offending and service characteristics. J Learn Disabil Offen Behav 2010; 1: 515.
10 Health and Social Care Information Centre. Learning Disability Census Report. HSCIC, 2015.
11 NHS England. Care and Treatment Review: Policy and Guidelines. NHS England, 2015.
12 NHS England. People with a Learning Disability Have a Key Role – Dr Julie Higgins. NHS England, 2016. Available at https://www.england.nhs.uk/learningdisabilities/2016/05/26/julie-higgins-3/ (accessed 15 September 2016).
13 Cumella, SJ. Public policy in intellectual and developmental disability. Curr Opin Psychiatr 2010; 23: 417–20.
14 Health and Social Care Information Centre. Inpatients Formally Detained in Hospitals under the Mental Health Act 1983, and Patients Subject to Community Treatment: Annual Report, England, 2013/14. HSCIC, 2014.
15 Care Quality Commission. Count Me in 2010: Results of the 2010 National Census of Inpatients and Patients on Supervised Community Treatment in Mental Health and Learning Disability Services in England and Wales. CQC, 2011.
16 Department of Health. Valuing People: A New Strategy for Learning Disability for the 21st Century. Department of Health, 2011.
17 Wolfensberger, W. Social role valorization: a proposed new term for the principle of normalization. Ment Retard 1983; 21: 234–9.
18 Mansell, J, Ericsson, K. Deinstitutionalisation and Community Living: Intellectual Disability Services in Scandinavia, Britain and the USA. Chapman and Hall, 1996.
19 Aiden, H, McCarthy, A. Current Attitudes Towards Disabled People. Scope, 2014.
20 Equality and Human Rights Commission. Hidden in Plain Sight: Inquiry into Disability-Related Harassment. EHRC, 2011.
21 Department of Health. The Bradley Report: Lord Bradley's Review of People with Mental Health Problems or Learning Disabilities in the Criminal Justice System. Department of Health, 2009.
22 Loucks, N. No One Knows: Offenders with Learning Difficulties and Learning Disabilities. Review of Prevalence and Associated Needs. Prison Reform Trust, 2006.
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BJPsych Bulletin
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  • EISSN: 2056-4708
  • URL: /core/journals/bjpsych-bulletin
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The impact of transforming care on the care and safety of patients with intellectual disabilities and forensic needs

  • John L. Taylor (a1), Iain McKinnon (a2), Ian Thorpe (a3) and Bruce T. Gillmer (a3)
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eLetters

Missing the Point

John L. Taylor, Professor of Clinical Psychology/Consultant Clinical Psychologist, Northumberland, Tyne & Wear NHS Foundation Trust and Northumbria University
27 September 2017

As the lead author on the paper on the impact of Transforming Care on people with intellectual disabilities and forensic needs, I would like to comment on some of the points raised by Dr Marshall in his letter dated 15 August 2017. Dr Marshall’s solution to reducing ‘learning disability’ bed numbers as envisaged by the Transforming Care programme is to turn those with borderline intellectual disabilities out of beds in specialist secure services. This seems to be a very 20th century psychiatry approach to service provision: relying on unreliable diagnostic categories and cut-off scores, rather than looking at the patient’s presentation, level of functioning, and formulation of needs within a neurodevelopmental disability framework. Dr Marshall suggests that many such people would manage in prison. I’m not aware of any research evidence to support this view which was presumably not shared by his psychiatrist colleagues who made the medical recommendations required for the courts to divert these people from the criminal justice system to hospital for treatment and rehabilitation.

Whether length of stay in hospital is increased or reduced by people with intellectual disabilities being admitted to general mental health beds, it is clear the Transforming Care policy of decommissioning specialist intellectual disability beds in the NHS is not resulting in the planned reduction in the numbers of people with intellectual disabilities in hospital inpatient beds. At the end of March 2015, before the national plan (1) was implemented, there were 2,395 inpatients with intellectual disabilities; at the end of July 2017 the number was 2,445 (2). This despite the huge amount of resources that have been diverted into this programme. As significant numbers of NHS intellectual disability beds have closed during this period it is interesting to speculate where these inpatients are now receiving services. In 2010 the percentage of intellectual disability beds provided by the independent sector was 33%; by 2016 that figure had risen to 52% (3). The view expressed in our paper was that this was a likely outcome of the Transforming Care programme that had, and continues to fail to invest in community services to support these patients. That was the point we were making. Whilst aspiring for ‘mythical perfection’ may be misguided, striving for mediocrity is no alternative.

Finally, Dr Marshall suggests that a more honest approach to dealing with offenders with intellectual disabilities might be to take learning disability out of the Mental Health Act and replace it with a different system. That could be a case of being careful what you wish for. Jurisdictions where this happened have tended to have to re-invent systems of detention for offenders with intellectual disabilities that are more draconian, less effective and provide fewer safeguards than our own imperfect system.

1. NHS England. Building the right support: a national plan to develop community services and close inpatient facilities for people with a learning disability and/or autism who display behaviour that challenges, including those with a mental health condition. NHS England, 2015. https://www.england.nhs.uk/wp-content/uploads/2015/10/ld-nat-imp-plan-oct15.pdf



2. NHS Digital. Learning disability services monthly statistics. England commissioner census (Assuring Transformation), July 2017. file:///C:/Users/johtaylor/AppData/Local/Microsoft/Windows/INetCache/IE/TGJ89FIB/ldsm-Jul-17-exec%20(1).pdf

3. Brown, M., James, E. & Hatton, C. A trade in people: The inpatient healthcare economy for people with learning disabilities and/or Autism Spectrum Disorder. Lancaster University: Centre for Disability Research, 2017.

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Conflict of interest: Lead author of the index article.

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The myth of perfection

Thomas Marshall, Consultant Psychiatrist, Tees, Esk and Wear Valleys NHS Foundation Trust
15 August 2017

As a forensic learning diabilities (LD) consultant in the North East, I was interested to read the recent paper by Thorpe, et al (1). However, I take a more critical view of existing services.

Until very recently, the main priority of forensic LD services has been risk management, through detention in either hospital or residential facilities; the mark of success was that the patient did not reoffend. I note that the paper refers to patients served by the inpatient facilities as 'mild/borderline in intellectual disability terms', which suggests that some are not in fact learning disabled at all. I suspect that if these patients were discharged then much of the proposed bed reduction could be achieved. Many individuals with LD can cope in prison, and may well prefer it as they have a release date, and other prisoners are less disturbed than the patients in secure care.

I do not think that bed stays will be increased by admission to adult mental health beds, as these services tend to discharge patients as soon as they are settled, rather that expecting them to be risk free. It would have been more honest of the government to have taken LD out of the Mental Health Act (as they did in New Zealand) and put in place some system for dealing with LD offenders who were not fit to plead, or could not manage in prison with fixed terms for meaningful judicial review.

References

1.Taylor, JL. McKinnon, I. Thorpe, I. Gillmer, BT. The impact of transforming care on the care and safety of patients with intellectual disabilities and forensic needs. BJPsych Bull Aug 2017, 41 (4) 205-208

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Conflict of interest: None Declared

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The problem of stepping down.

Taylor and colleagues provide a considered critique of the National Health Service (NHS) England Transforming Care programme. A further point that they could have made concerns 'step down' beds.

Medium-secure beds are nationally commissioned by NHS England and provide treatment to patients with severe risk issues. As their clinical state improves, they would traditionally – and sensibly – move down to low-secure and then non-secure (rehabilitation) units prior to discharge.

The Transforming Care programme requires a 50% bed reduction at all levels of security. As it is exceptionally unlikely that discharging someone from a medium-secure unit directly to the community would be possible – let alone sensible – it follows that a 50% reduction in medium-secure beds necessitates an increase in low-secure and open beds. This is not likely to occur, as these beds are locally commissioned by clinical commissioning groups (CCGs), not NHS England. I doubt that any CCG has the appetite to simultaneously get NHS England off the hook while laying itself open to criticism from NHS England.

In the absence of that increase – or at the very least no decrease – in such beds, secure beds will 'silt up', with all the repercussions defined by Taylor and colleagues.
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Conflict of interest: None Declared

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