In June 2018, Voluntary Organisations Disability Group (VODG) produced a report called The challenges and solutions of Transforming Care. NHS England, under its national plan ‘Building the Right Support‘ is calling for an improvement in health and care services so that people can live in the community with the right support, and closer to home. VODG developed a task force for London focusing on discharging 27 people from in-patient services to the community. Their report shares their finding and recommendations.
In my career, with strong teams around me, we have tried, succeeded and occasionally failed people with a learning disability who were living in patient services across the UK to move out into their community. It is not easy. There are a number of complex, dynamic reasons, with local idiosyncrasies that need understanding and navigating to succeed.
Over the years I have assessed many people, young and old, in specialist locked- rehabilitation services, often under section. I have never met anyone who couldn’t be supported in the community. Period. Not one. Most were detained on a section 3 or 37/41, most for too long to think about. Too many MDTs were reluctant to discharge, despite commissioner request. Too many in-patient services were risk averse to taking people off their sections. We find ourselves stuck when the legal framework prevents the move on and the ‘leap’ is perceived too risky, or not in their best interest.
Each time I assess I wonder why I’m surprised, heartbroken and angry at the limitations they have put on this population group, but each time I am.
I assessed someone recently. He was 17 years old but was being held in a locked rehab environment due to a deterioration in his mental health and behaviour. A poorly improvised environment and the wrong support model was effectively preventing him being discharged. Dozens of providers would be willing and able to support this young man, in his own home in the community, but it requires investment, creative thinking and an alignment of housing, funding, training and development and a trust in the provider to make this happen.
Of the 27 people from inpatient services VODG worked with, they too noted that ‘every single one of the people would be able to live in the community with the right support and housing’. However, the report concludes progress is hampered by multiple, often system wide issues.
My experience is that the challenge providers face is somewhat of a perfect storm. It is proving considerably more complex to achieve the objectives of the Transforming Care agenda for a number of reasons;
- The commissioning model means that each referral has to meet a series of targets and budgets and are set in national competition with other providers.
- Massive budget cuts from central government is being passed onto local authorities meaning local authorities pass this saving task onto providers.
- Providers have to look for savings internally – teams are restructured, reduced and additional support services disappear, inhibiting the recourses for growth.
- ‘Front loading’ or investing at the outset of a new project is a harder sell to boards, or no longer commercially viable.
- Legislation change in living wage and sleep-ins is having to be shouldered by providers. Even if living wage is offered by councils, it does not cover ‘on costs’.
- Achieving success in the housing market is challenging. Bringing together the RSL, developer and funder whilst ensuring the cost of additional fit out, and long-term maintenance is covered is often too complex for providers to address. developers and RSL struggle to meet their model on single person services.
- Discharging from inpatient services can be a long and drawn out process with delays and set backs. The provider is now limited in how long they can financially support this process.
I won’t claim to have all the answers but I know it requires a commitment from a provider to invest in this model and ensure good detailed assessment is carried out by experienced, knowledgable practitioners who can offer clarity around cost. Providers need strong leaders who can navigate a complex pathway. True partnership with the MDT, provider, family and stakeholders are needed to be able to build and sustain honest relationships with commissioners.
VODG reported that a ‘one provider approach’ (whereby a provider is commissioned at the outset) will make the process more efficient, rather than a number of providers competing for the same individual.
Funding needs to be available for transition and further detailed assessment work. VODG notes ‘there is a lack of understanding and a gap in knowledge about the costs of community support for people who have a history of being institutionalised. Commissioners need to understand and address the areas I have raised in this paper and understand the complexity of the situation for providers today.
We need to encourage a commitment to discharge from inpatient hospitals, and financial resolutions that allow providers to be creative and give them the freedom to get things wrong occasionally. Without these shifts, nothing will ever change or improve.
VODG report that bespoke housing in a cluster is the preferred model for tenants, with communal space available should people want this. My experience supports the model of the cluster as it enables services to access a wider pool of staff. This allows for more supervision, breaks and an ability to swap the teams as and if necessary. However, my experience of a shared area only works if it is managed very carefully and is tenant led, not for staff’s convenience, or to replace accessing ordinary community facilities. Property developers and RSLs also look for larger clusters to enable their model to work. as single person dwellings is an expensive way to develop housing. This however should not limit peoples choice of housing.
The success of the VODG project demonstrates it can be achieved. There are wonderful success stories across the UK, some of which I have been lucky enough to be involved in. The paper highlights challenges and offers a resolution confirming my view that we all need to put aside personal agendas and instead focus on drivers and incentives that allow us all to invest in the people we have wronged for so long.
Andy Callow
Andy Callow Associates
June 2018
Andy Callow Associates 