A survey of learning disability inpatient services in Scotland in 2007

'Why are we stuck in hospital?' Barriers to people with learning disabilities/autistic people leaving 'long-stay' hospital: a mixed methods study

Background

Transforming care so that people with learning disabilities and/or autistic people can receive support at home rather than in hospital settings is a key priority, but progress has been slow. Despite significant national debate, little previous research has engaged directly with people in hospital, their families or front-line staff to understand the issues from their perspectives.

Objectives

This research seeks to better understand the experiences of people with learning disabilities and/or autistic people in long-stay hospital settings, their families and front-line staff - using this knowledge to create practice guides and training materials to support new understandings and ways of working.

Design

Following a structured review of the literature, we sought to work with up to 10 people with learning disabilities and/or autistic people in three case-study sites (2021-22), supplementing this with interviews with family members and commissioners; interviews/focus groups with hospital staff, social workers, advocates and care providers; information from case files; and observations of multidisciplinary meetings.

Setting

Three 'long-stay' hospital settings in England.

Participants

Twenty-seven people in hospital, together with families, health and social care staff and commissioners.

Results

• People in hospital report widespread frustration, feel that hospital environments are not conducive to getting/staying well, and face multiple barriers to leaving hospital. Without someone to fight for them, people struggle to overcome the inertia built into our current systems and processes. • Front-line staff are equally frustrated and describe a complex and seemingly dysfunctional system which they find almost impossible to navigate. • Hospital staff from different professional backgrounds do not have a shared sense of how many people really need to be in hospital or how many people could be cared for in different settings - suggesting that different definitions, world views and professional judgements might be at play. • Hospital staff are frustrated about what they see as the difficulty of discharging people into community services, while community services are equally frustrated about what they see as a risk-averse approach which they feel can lack an up-to-date knowledge of what is possible to achieve in the community. • Despite over a decade of policy attempts to resolve these issues, very significant barriers remain.

Limitations

This research explored the experiences of a small number of people, but has done so in significant depth. The research was undertaken in secure settings, during COVID and in a difficult external policy and practice context, and so has had to be very flexible and empathetic in order to build relationships and make the research possible. Future research could helpfully consider the needs of people from black and minority ethnic communities, the extent to which the experiences of people on forensic pathways are similar to/different from other people's experiences (including perspectives from the criminal justice system), and what happens to people in the long term after they leave hospital.

Conclusions

Working to make the voices of people with learning disabilities and/or autistic people (as well as the staff who support them) centre stage is complex and sensitive. However, this lived experience/practice knowledge is a crucial resource if we are going to develop better policy and practice solutions in the longer term.

Study registration

This study is registered at www.researchregistry.com (researchregistry6124).

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR130298) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 3. See the NIHR Funding and Awards website for further award information.

'Why are we stuck in hospital?' Understanding delayed hospital discharges for people with learning disabilities and/or autistic people in long-stay hospitals in the UK

Despite longstanding efforts at de-institutionalisation, around 2000 people with learning disabilities and/or autistic people in England currently live in hospital settings, amidst reports of protracted stays, limited progress towards living more ordinary lives and scandals of abuse and poor care. Yet, there is relatively little research on why people with learning disabilities and/or autistic people are delayed in hospitals, and what exists has significant limitations. In particular, previous studies have rarely talked directly to people with learning disabilities and/or autistic people, their families and frontline staff about their experiences of living or working in such settings, the barriers to discharge and what would help more people to lead chosen lifestyles. This paper presents the findings of a structured literature review conducted between January and March 2021 on delayed discharges of people with learning disabilities in long-stay hospital settings. It investigated: the proportion of people with learning disabilities delayed in long-stay hospital settings, the suggested reasons for these delays and the proposed solutions. The literature reported delays for 11%-80% of inpatients in different settings. The reasons reported are related either to particular characteristics of the person (which we find problematic) or limitations of the system supporting them. However, delays were defined and reported inconsistently, reasons usually lacked depth and detail, and the majority of included studies did not engage directly with the people living in long-stay settings, their families or frontline staff. Without listening to these voices, genuine solutions will be difficult to find.

A systematic review of in-patient psychiatric care for people with intellectual disabilities and/or autism: effectiveness, patient safety and experience

BACKGROUND

An increasing number of children, adolescents and adults with intellectual disabilities and/or autism are being admitted to general psychiatric wards and cared for by general psychiatrists.

AIMS

The aim of this systematic review was to consider the likely effectiveness of in-patient treatment for this population, and compare and contrast differing models of in-patient care.

METHOD

A systematic search was completed to identify papers where authors had reported data about the effectiveness of in-patient admissions with reference to one of three domains: treatment effect (e.g. length of stay, clinical outcome, readmission), patient safety (e.g. restrictive practices) and patient experience (e.g. patient or family satisfaction). Where possible, outcomes associated with admission were considered further within the context of differing models of in-patient care (e.g. specialist in-patient services versus general mental health in-patient services).

RESULTS

A total of 106 studies were included and there was evidence that improvements in mental health, social functioning, behaviour and forensic risk were associated with in-patient admission. There were two main models of in-patient psychiatric care described within the literature: admission to a specialist intellectual disability or general mental health in-patient service. Patients admitted to specialist intellectual disability in-patient services had greater complexity, but there were additional benefits, including fewer out-of-area discharges and lower seclusion rates.

CONCLUSIONS

There was evidence that admission to in-patient services was associated with improvements in mental health for this population. There was some evidence indicating better outcomes for those admitted to specialist services.

Researching outcomes from forensic services for people with intellectual or developmental disabilities: a systematic review, evidence synthesis and expert and patient/carer consultation

Background

Inpatient services for people with intellectual and other types of developmental disabilities (IDD) who also have forensic or risk issues are largely provided in secure hospitals. Although this is a health service sector with high levels of expenditure, there is limited empirical information on patient outcomes from such services. In order for a future substantive longitudinal outcomes study in forensic IDD services to be informed and feasible, more needs to be understood about the outcome domains that are of relevance and importance and how they should be measured. A preliminary series of studies was therefore undertaken.

Objectives

To synthesise evidence in relation to the outcome domains that have been researched in the existing literature from hospital and community forensic services for people with IDD, within the broad domains of service effectiveness, patient safety and patient experience. To identify a definitive framework of outcome domains (and associated measures and indicators) based both on this research evidence and on the views of patients, carers and clinicians. To synthesise the information gathered in order to inform design of future multisite longitudinal research in the sector.

Design

Three linked studies were conducted. Stage 1 was a systematic review and evidence synthesis of outcome domains and measures as found within the forensic IDD literature. Stage 2 was a consultation exercise with 15 patients with IDD and six carers. Stage 3 was a modified Delphi consensus exercise with 15 clinicians and experts using the information gathered at stages 1 and 2.

Results

At stage 1, 60 studies that researched a range of outcomes in forensic IDD services were identified from the literature. This resulted in the construction of an initial framework of outcome domains. The consultation with patients and carers at stage 2 added to these framework domains that related particularly to carer experience and the level of support post discharge in the community. The Delphi process at stage 3 confirmed the validity of the resulting framework for clinician. This survey also identified the outcome measures preferred by clinicians and those that are currently utilised in services. Thus, indicators of appropriate measures in some important domains were identified, although there was a paucity of measures in other domains.

Conclusions

Together, these three linked studies led to the development of an evidence-based framework of key outcome domains and subdomains. A provisional list of associated measures and indicators was developed, although with the paucity of measures in some domains development of specific indicators may be required. With further refinement this could eventually be utilised by services and commissioners for comparative purposes, and in future empirical research on outcomes in forensic IDD services. An outline research proposal closely linked to recent policy initiatives was proposed. Limitations of the study include the relatively small number of carers and patients and range of experts consulted.

Future work

This would comprise a national longitudinal study tracking IDD in patients through hospitalisation and discharge.

Study registration

This study is registered as PROSPERO CRD42015016941.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

A systematic review and synthesis of outcome domains for use within forensic services for people with intellectual disabilities

BACKGROUND

There is limited empirical information on service-level outcome domains and indicators for the large number of people with intellectual disabilities being treated in forensic psychiatric hospitals.

AIMS

This study identified and developed the domains that should be used to measure treatment outcomes for this population.

METHOD

A systematic review of the literature highlighted 60 studies which met eligibility criteria; they were synthesised using content analysis. The findings were refined within a consultation and consensus exercises with carers, patients and experts.

RESULTS

The final framework encompassed three a priori superordinate domains: (a) effectiveness, (b) patient safety and (c) patient and carer experience. Within each of these, further sub-domains emerged from our systematic review and consultation exercises. These included severity of clinical symptoms, offending behaviours, reactive and restrictive interventions, quality of life and patient satisfaction.

CONCLUSIONS

To index recovery, services need to measure treatment outcomes using this framework.

DECLARATION OF INTEREST

None.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Attribution (CC BY) licence.

Delayed discharge from intellectual disability in-patient units

Aims and method We undertook a cross-sectional service evaluation of the reasons and extent of delay in the discharge process in an intellectual disability hospital over a 12-month period. Delays at each stage of the discharge process are also quantified in this study.

Results We found that discharge was delayed for 29% of patients during the study period. The majority (78.5%) was due to awaiting completion of assessment of future care needs and waiting for public funding.

Clinical implications Commissioners (health and social), provider trusts, regulators and community providers should consider the reasons for delay in the discharge process and adopt a whole systems approach to discharge planning. This is highly relevant in light of recommendations by the Department of Health following the Winterbourne View scandal, which has raised concern about patients staying in intellectual disability in-patient units too long and for the wrong reasons.

Impact of care pathway-based approach on outcomes in a specialist intellectual disability inpatient unit

Specialist intellectual disability inpatient units have come under increased scrutiny, leading to questions about the quality of service provision in this sector. A care pathway-based approach was implemented in such a unit and its impact on outcome variables was measured. The care pathway-based approach resulted in the turnover of more patients, increased capacity for admissions to the unit, reduced lengths of stay in hospital, timely assessments and treatments, which resulted in better outcomes in patients. Care pathway-based approach to service provision provides not only better outcomes in patients but also a reliable way of ensuring true multi-agency working and accountability. If used widely, it can reduce the variability in the quality of current service provision.

Mental health services for people with intellectual disabilities

PURPOSE OF REVIEW

This review summarizes recent research into psychiatric services for adults with intellectual disabilities, with a particular focus on inpatient care.

RECENT FINDINGS

People with intellectual disability appear to be admitted with more severe problems and receive more interventions than those without intellectual disability when admitted to general psychiatric units. Qualitative research has shown poor standards of care on some general psychiatric inpatient units. Studies of supported generic inpatient units have reported successful outcomes, supported by qualitative studies of satisfaction. Length of stay for people with intellectual disability is not consistently longer on specialist than general psychiatric units. Delayed discharge and restrictive practices, however, still need addressing. The important components of community mental health services have been evaluated from the points of view of psychiatrists, patients and carers. Emergency provision of psychiatric assessment and care remains a problem in some centres.

SUMMARY

There have been few randomized controlled trials in this field; however, uncontrolled comparisons and service evaluations suggest positive outcomes in specialist services. Qualitative work has made important contributions to understanding the patients' and carers' experiences. Further work should focus on the measurements of outcome and satisfaction.

Workforce development and challenging behaviour: training staff to treat, to manage or to cope?

Staff working directly with adults' challenging behaviours in learning disability services need to be very good at what they do. They also need to want to do the job. A theory-practice gap exists, however, between what is known about effective, evidence-based approaches and whether and how these are used in person-centred community services. Many frontline staff working with people with the most serious challenging behaviours do not have the skills to implement programmes to change behaviour. This discussion article reviews workforce development in the context of clinical and service guidelines and asks whether the legitimate purview of frontline staff is treating challenging behaviour, managing it or simply coping with it on a daily basis, whilst maintaining the best quality of life possible for service users.