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The purpose of this clinical audit was to review the adherence to the 2017 care and treatment review policy across two NHS assessment and treatment units. Care and treatment reviews should be offered to people with an intellectual disability and/or autism who are at risk of admission into a mental health hospital.

Admission and discharge data was collected across two assessment and treatment units between January 2019 and December 2022. Adherence to the care and treatment review policy was also reviewed as was length of inpatient stay. A retrospective evaluation was conducted. Triangulation of data was collected via the trusts’ electronic patient record system and NHS analytics team. Descriptive statistics, Mann–Whitney U test and a one-way ANOVA with post hoc tests were used in the analysis.

An increase in behaviours of challenge and deterioration of mental health were the main reasons for admission. Forty-nine percent (30) of those admitted to the assessment and treatment units accessed a care and treatment review. Care and treatment reviews were more frequently provided for individuals experiencing longer inpatient stays.

There is limited evidence relating to outcomes and impact of care and treatment reviews. Further research is required to explore effectiveness of care and treatment reviews to understand benefits and appropriately prioritise resource.

The purpose of this paper is to evaluate the impact of a changing commissioning landscape on the provision of specialist acute inpatient care from the perspective of a small category 2 unit in London.

The authors conducted a retrospective survey of all referrals to the unit in 2012 and 2013.

There has been an increase in the referrals and admissions to the unit with referrals covering a wider catchment area. This has resulted in a doubling of the average distance between the unit and the respective catchment areas that patients and their relatives have to travel. The majority of admissions were transfers from mainstream mental health services. There has been a reduction in the mean length of stay.

This survey looks at trends in one category 2 unit in an outer London Borough and therefore, limits generalisability. The data collection was retrospective and there was no information on patients requiring admission but not being referred to the unit.

There continues to be a need for category 2 admission units to serve the needs of a small group of patients with intellectual disability presenting with mental health needs and behavioural problems. Consideration needs to be given to the entire mental health and challenging behaviour care pathway, including the small but crucial element of specialist inpatient management if services are to remain local and responsive to the needs of this group of patients and their carers.

An ill-planned reduction in the number of specialist inpatient units without viable community services, risks perpetuating a situation where patients and their relatives have to travel long distances to obtain appropriate specialist help. Longer geographical distances could also potentially hamper closer liaison between the unit and the community services, thereby reducing the degree of oversight and prolonging the transition and discharge process.

This survey highlights the impact of recent commissioning and service changes on delivery of specialist in patient services for adults with intellectual disability in the immediate aftermath of the Winterbourne Review.

This paper aims to examine the prevalence and reasons for delayed discharge from two regional assessment and treatment units (ATUs) for people with learning disabilities, in line with the transforming care agenda.

This is a retrospective evaluation of 44 admissions and discharges from two ATUs from February 2019 to March 2022.

Of 44 admissions who were discharged during the included period, 20 experienced delays in their discharge. Delayed discharges occurred despite the two ATUs meeting standards for length of assessment and treatment as specified by the Learning Disability Professional Senate. The most prevalent reasons for discharge delays were identification of a new placement, recruitment of care staff and building work.

This paper offers an in-depth evaluation of recent delayed discharges from two regional ATUs, highlighting the most common reasons for delays and offering suggestion for reducing delays in future.

Secure inpatient services for people with intellectual disability are provided in a piecemeal way, often without strategic commissioning. We describe how we conducted a needs assessment that enabled us to develop a new service for men with intellectual disability who often had substantial additional mental health needs. Consulting with all stakeholders was essential, and we found the service user and family perspectives particularly helpful. We had to make special arguments for some aspects of the treatment programme. We found that foundation trusts that are able to develop services at financial risk, before contracts are signed, enabled development to take place at a faster pace. Good relationships with community teams have been essential, as has true integration with mainstream forensic services. Maintaining a relationship with commissioners was a particularly challenging aspect, perhaps because the development was provider‐led. Despite these challenges, many people with intellectual disability with very high needs are being supported much nearer to home.

The purpose of this paper is to evaluate whether two regional intellectual disability (ID) assessment and treatment (A&T) units in England were meeting the recommended length of stay stipulated by the Learning Disability Professional Senate, in line with the Transforming Care (TC) agenda. A secondary purpose of the study was to evaluate the reasons for admissions and delayed discharges in order to inform how to reduce these.

A retrospective evaluation of 85 admissions across two A&T units was conducted over a three-year period (2013–2016) following publication of the TC agenda.

There were 85 admissions compared to 71 discharges. Of the 85 admissions, 11 were readmissions. The most common factors thought necessary to prevent admission were early support for care providers or alternative service provision. There were barriers to discharge in over half of admissions; the main reason was a lack of suitable service provision.

The study suggests that providing specific support or training to care providers could prevent (re)admission and ensure shorter admissions. Further research to establish reasons for the reported lack of suitable providers would be beneficial.

This study provides current admission and discharge rates for regional A&T units, as recommended by the TC national guidance. It also provides potential reasons underlying preventable admissions and delayed discharges and therefore indicates what might be necessary to prevent admissions and reduce the length of inpatient stays for people with ID and/or autism.

The purpose of this paper is to describe the current situation in relation to restrictive interventions, and some actions that could be taken to reduce them. The quality of care provided by inpatient services for people with intellectual disabilities has come under increasing scrutiny in recent years – from Winterbourne View in 2011 to Whorlton Hall in 2019, there has been increasing concern that admission to hospital does not always result in a good outcome for the patients. For some people, it has resulted in further deterioration in their physical and mental health, separation from families and supports and reduced probability of living as part of their community. This is in spite of knowledge and evidence of what good practice looks like.

This paper examines the extent to which inpatient services deliver good practice in treatment and care and, where this is not happening, the extent to which they are subject to effective governance.

People admitted to inpatient services can be at risk of poor-quality care and the overuse of restrictive interventions. There is guidance available that addresses what should be in place for them to receive high-quality care and treatment, and this clearly is available to many people. However, others can find themselves placed in increasingly restrictive environments and in circumstances where their human rights are at risk of being breached. There is increasing evidence that these services do not follow good practice guidance in terms of staff skills, development and implementation of effective care plans and governance arrangements that address these issues. Regulators, commissioners and managers could, and should, focus on these issues to ensure that the most vulnerable receive the care and treatment they need while in hospital.

Service providers are aware of the difficulties in developing alternative community services. This places even more importance on the need to ensure that care and treatment in hospital is of a good standard, and that the use of restrictive interventions is minimised. McGill et al. (this issue) describe the features of a capable environment and it may be that hospitals consider that the requirements are unlikely to be implemented effectively in a ward/unit setting. However, a shift of focus in doing this could result in a reduction in restrictive interventions and a better experience – potentially for both the staff and the patients. And families could have some reassurance that their relative was receiving the best quality care and treatment, and that their human rights were being upheld.

This commentary explores the challenges and themes enumerated by the associated article “Why am I still in hospital? Evaluation of delayed discharges from two learning disability assessment and treatment units in England”. This commentary broadens and outlines the research’s background, premise and potential impact. This paper aims to critically examine the evidence on this subject.

This commentary considers the attitudes to inpatient care for people with learning disabilities in the past decade and outlines a possible compact for the future.

Contrary to popular and emotive beliefs that using specialist inpatient psychiatric settings for people with learning disabilities is universally a poor practice, there are defined occasions when such settings are needed and imperative in the clinical pathway. If people with learning disabilities can access inpatient settings at the right time for the right reason, psychiatric outcomes could be improved. Timely discharge is imperative and currently lacking due to a lack of suitable engagement mechanisms between inpatient settings and the community. Thus, evidence-based outcome tools are essential to facilitate appropriate discharge.

There is an ongoing debate on the value and utility of specialist inpatient psychiatric units for people with learning disabilities. This commentary provides a balanced, evidence-based insight into this discussion.

The purpose of this paper is to describe in detail the treatment pathway utilised in a male medium and low secure intellectual disability (ID) service. Over the preceding five years, service users have followed the outlined treatment pathway. The current paper offers case study material to illustrate the care pathway.

The treatment pathway is described and two case examples are provided, illustrating participation in the pathway. Evaluative data are provided on length of hospitalisation, direction of pathway at discharge and risk reduction as assessed by the HCR-20, SVR-20 and HONOS Secure measures.

The case examples provided document the assessment and treatment of two male offenders with ID, outlining their treatment pathways, subsequent reductions in assessed risk and their successful community discharge.

A comprehensive treatment pathway is outlined together with the theoretical rationale, with illustrative case examples.

This study aims to understand whether psychotropic prescribing practices for people with intellectual disabilities are in keeping with best practice guidelines.

This service evaluation project was a retrospective analysis of routinely collected data from the care records of all 36 people with intellectual disability discharged from an intellectual disability assessment and treatment unit during the first five years of the Stop Over medicating People with Intellectual Disabilities and/or autistic people (STOMP) initiative. Data were gathered at four time points (pre-admission, discharge, 6- and 12-month follow-up) before being analysed to understand whether psychotropic prescribing differed among people with different clinical characteristics/traits/diagnoses. Changes over time were also explored to ascertain whether and how prescribing altered from admission to discharge, and over the subsequent year of community living.

Most people with intellectual disabilities left the assessment and treatment unit on fewer regular psychotropic medications and at lower doses than at admission. These optimised regimes were still apparent 12 months post-discharge, suggesting effective discharge planning and community care packages. Inpatients with severe intellectual disabilities generally received more anxiolytics and hypnotics, at higher doses. Autistic people tended to receive more psychotropics in total and at higher cumulative doses, a pattern that persisted post discharge. A third of the sample were admitted on regular anti-psychotic medications despite having no corresponding psychotic diagnosis, a proportion that remained relatively stable through discharge and into the community.

This study highlights subsets of the intellectual disability population at particular risk of receiving high doses of psychotropics and a feasible template for providers intending to undertake STOMP-focused evaluations.