The substantive findings

The total number of in-patients in units for people with learning disabilities fell by 21% between 2006 and 2010. This was the net effect of a drop of 33% in the number of NHS patients and an increase of 26% in the (much smaller) number in independent sector

placements. The proportion of patients in independent sector placements rose from 20% to 33%. In the independent sector, the growth reported was mainly in wards designated as long-stay or rehabilitation; the number of independent sector placements reported as A&T changed little. The corresponding trends in NHS facilities were obscured by data problems, but overall roughly 60% of A&T patients were in NHS placements and 40% in the

independent sector.

Amongst independent sector A&T providers there seemed to be a trend in the direction of a larger number of smaller sized units. This was not clear in the NHS sector.

The fall in total in-patient numbers mainly related to patients in general (non-secure) wards. Their numbers fell by 20% from 2007 to 2010 (security level data were missing from the 2006 data). By comparison numbers in medium secure beds fell by only 5% whilst numbers in low secure beds rose by 1%. Independent sector providers were looking after 22% of patients in general (non-secure) A&T units, but 50% in low secure and 60% in medium secure A&T placements.

Overall, 42% of all patients were detained under the Mental Health Act. The proportion in A&T units was higher than in other types of ward (61% vs. 31%). Three in five of those detained under the Mental Health Act, were under civil orders (imposed by medical and social work staff), two in five were under criminal orders (imposed by courts or on prisoners). Higher proportions of those in independent sector A&T units were detained (74%) than in NHS A&T units (53%). Almost a quarter of patients in low secure wards were not detained under the Mental Health Act; this was similar in the two sectors. Across all ward types and specifically in A&T wards, the proportion of patients with informal legal status fell over the four years, whilst numbers detained under the Mental Health Act, rose. The greatest rise was seen in patients detained under criminal orders.

Overall duration of stay in A&T units was long. In the most recent census, 55% of patients had been in hospital a year or more, and 38% two or more years. Duration of stay was significantly longer in both low and medium secure wards than in non-secure. For non- secure wards, duration of stay was considerably greater in independent sector- than in NHS units. However for medium secure units, a smaller proportion of patients in independent sector than in NHS placements had stayed more than a year.

5.2.2. Adverse patient experiences

Patterns of care clearly differed between secure and non-secure placements, and those in independent and NHS services. This made exploration of possible differences in the pattern of those details of patients’ experience of care that were reported in the census complex. Five types of patient experience were reported. In A&T units:

7% of patients experienced seclusion in the preceding three months. This appeared to be restricted to a minority of providers;

22% experienced at least one accident; 35% suffered an assault;

41% were subject to hands-on restraint; and 27% self-harmed.

For a minority of patients, these were common occurrences. For example, in the previous three months in A&T units:

6% of patients suffered 10 or more assaults;

10% were subject to 10 or more episodes of hands-on restraint.

At increasing levels of security, seclusion was more common, and accidents, assaults and self-harm less common. In simple comparisons, not making allowance for possible

differences between the groups of patients concerned, seclusion, assaults, restraint and self- harm were all more common in independent sector hospitals, and accidents marginally more common in NHS ones. When hospitals at the three levels of security were compared

separately the difference between the two sectors became sharper, with differences almost always favouring NHS hospitals.

We undertook a multivariate analysis to explore the patterns of these experiences, making allowance for all the patient and contextual variables for which data were available to us. At this stage we took self-harming behaviour to be a patient characteristic possibly predictive of a need for restraint or seclusion rather than as an outcome. On this basis we explored the significance of both the sector of provision and individual providers for patients’ risk of the other four patient experience outcomes. The optimum model, making allowance for ward security level, and patients’ ages, genders, legal status, durations of stay and status with respect to presence of autism, mobility disabilities and self-harming behaviour, indicated that in comparison to NHS patients, those looked after by independent sector providers had a similar chance of seclusion or accidents, but a 33% greater risk of suffering at least one assault and a 61% greater risk of experiencing hands-on restraint. These differences between the independent and NHS sectors, whilst important, cannot indicate what are the key elements of independent sector provision which lead to the association with these adverse outcomes. Further analysis suggested it was not simply differences in the frequency of out-of-area placement. They are, however, in line with the findings of the 150 urgent

inspections undertaken by the Care Quality Commission in the aftermath of the broadcast of the BBC Panorama Programme about Winterbourne View. Statistical analysis of these of these showed that learning disability services in independent sector hospitals were

significantly less likely than in NHS hospitals to be compliant with Care Quality Commission standards in relation care and wellbeing and safeguarding issues including prevention of abuse and use of restraint.2 3

Working from a modelled prediction of each patient’s likelihood of suffering each outcome based on all these factors except provision sector, we explored whether or not individual provider units were significantly statistically associated with additional or diminished risk according to the data submitted. Sufficient data were available for 109 providers. In half of these, patients were not at significantly increased or diminished risk. Amongst the rest, more providers were associated with increased than decreased risks of the experiences modelled being reported. There were examples of significantly high and significantly low rates of adverse patient experiences in both Independent and NHS hospitals.

Data about specific providers would not be sufficiently reliable for publication as it could be influenced by note-keeping and reporting practices as much as by clinical care. The data are also at least two years old and may thus not reflect the current situation. However even if individual units may be misleadingly represented by their reports, general patterns in the data are harder to dismiss.

5.2.3. Commissioning patterns

Our original questions mostly related to commissioning patterns. We established that the current prevalence of use of in-patient care varied substantially between PCTs, in ways which seemed to show a degree of geographic clustering. Commissioning for different levels of security also varied considerably between Strategic Health Authorities. Strategic Health Authority-level rates for all in-patients had a threefold range (from 7.5 to 24.0 patients per 1000 people with learning disability). Rates for in-patients in A&T beds had a fourfold range (from 2.7 to 11.1). The proportion of in-patients in some type of secure accommodation showed a similarly wide range. For all patients this was from 14% to 78%; for A&T patients from 29% to 88%. There seemed to be no obvious relationship between these two findings. Durations of stay in both general and low secure placements varied significantly and

substantially between Strategic Health Authorities; for medium secure placements the differences were not quite statistically significant, probably because numbers were too small for this type of analysis.

Analysis of the distance of placements from patients’ homes was not very satisfactory as the relevant data items had important limitations in detail, and, particularly for patients in

Authorities. London, the South East Coast and the South West Strategic Health Authorities placed particularly high proportions of patients outside their boundaries, whilst the North East and the East of England were numerically the most significant importers of patients. Among non-secure placements, those in hospitals outside the patients home Strategic Health Authority appeared to be substantially longer in duration.