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Lothian Learning Disabilities Service, 65 Morningside Drive, Edinburgh EH10 5NQ, email: Ros.lyall{at}lpct.scot.nhs.uk
Psychiatry of Learning Disabilities, Lothian Learning Disabilities Service, Edinburgh
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Abstract |
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To examine the use of specialist psychiatric beds for people with learning disability, created following the closure of a long-stay institution. Admission and discharge data were examined, including history of previous institutional admission, diagnosis at discharge and number of subsequent readmissions.
RESULTS
Out of 348 admission episodes, 59 were accounted for by 40 patients who were previously resident in the long-stay institution. Most admissions were for new patients from the community. Over time, admissions to the specialist unit decreased when occupancy reached and persisted at 100%, coinciding with a significant rise in admissions of adults with learning disability to general adult psychiatric wards.
CLINICAL IMPLICATIONS
Resettlement after closure of long-stay learning disability institutions has not been accompanied by a high readmission rate for former residents, but neither has there been a decreasing need for psychiatric beds for those with learning disability and severe psychiatric disturbance. Most of these admissions are for people with learning disability who are relatively new to the service. There has been a persistent problem with full occupancy of these beds, which reflects delayed discharges indicating a lack of community resources and an increasing demand for admission.
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Introduction |
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This view is supported by recent reports in news-papers (‘Minister in Court. No secure place could be found for Nicol (mental age 6) after he tried to kill himself 6 times in prison’, Sun 15 September 2005; ‘Killed by Special Brew. Woman with known autism died after drinking 5 cans of Carlsberg’, Metro, 12 May 2006). These items, which report incidents involving people with learning disability who have appeared to require a specialist service, have inevitably been couched in emotive terms. Nevertheless, reports saying that a mother has killed her son who had severe learning disability and Down syndrome because she could not get help with his increasing violence (Daily Mail 5 November 2005), and others where the failure to provide a specialist in-patient service has resulted in inappropriate placement in prison or even death are bound to raise levels of anxiety.
In 1994, agreement was reached between Lothian Health Board and the local authorities to close the locality long-stay institutions for people with learning disability and provide staffed residential places in the community. Although there had been a continuous reduction in people living in hospital for many years, the final phase of the process required an increase in funding. Transfer of resources from health to social work was included in the agreement to fund community developments.
Like many areas Lothian had substantial in-patient facilities for people with learning disability, which peaked in the 1960s and 1970s. In 1970 there were 1111 beds occupied (Scottish Home and Health Department & Scottish Hospital Services Committee, 1970) and a substantial reduction in size occurred over the next two decades. The final closure of Gogarburn Hospital and two smaller institutions took place between 1994 and 1999. As part of the re-provision, a specialist psychiatric assessment and treatment unit was created in the grounds of, and is administratively part of the locality general psychiatric hospital (Royal Edinburgh Hospital). The facility provides specialist beds for people with learning disability and additional mental illness, severe challenging behaviour or forensic problems. There are 24 acute beds in the service: 12 beds that are designed to cater for those with severe challenging behaviour in one building and a second unit with 12 beds that were designed to be used for assessment and treatment of mental illness in those with learning disability deemed unsuitable for treatment in a general adult psychiatric ward. Both units are locked and fit the description of low security. In practice the beds for those with challenging behaviour have been used as planned; it was surmised when they opened that the patients would often have severe learning disability and their behaviour problems would require long-term in-patient treatment. The beds in the acute assessment and treatment unit, however, rapidly became filled and it proved very difficult to return some patients to an appropriate community setting. One six-bed ward in the acute unit has become a more secure unit for those who have severe behaviour problems that involve risk of violence. Many have a diagnosis of autistic-spectrum disorder.
This study describes the use of the specialist beds as a component of psychiatric services for people with a learning disability in Lothian. In Lothian beds for general adult in-patients are in open wards which do not have any designated beds which can be used and adapted to those with learning disability. Patients with learning disability, who might require extra help with activities of daily living or a locked door to keep them safe, can only be catered for in the intensive psychiatric care unit which is usually used for very disturbed and violent general adult patients.
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Method |
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Data relating to admission of patients with learning disability to general adult psychiatric beds were also obtained from PIMS. All patients with a clinical diagnosis of learning disability were identified, and those known to the learning disability service or subsequently admitted to the specialist service were included in the calculations. Those with no active connection to the learning disability service were excluded. This procedure is conservative and restricts the analysis to those where the learning disability could be clearly validated by specialist psychiatrists in learning disability
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Results |
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Discharge diagnoses
The degree of learning disability was recorded for 167 of the 213 people
admitted; 63% were recorded as having mild, 30% moderate and 7% severe
learning disabilities. In addition to learning disability, 244 additional
diagnoses were made in these 213 individuals
(Table 1); some patients had
multiple additional diagnoses.
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Admissions to general psychiatric beds
Table 2 shows the number of
admissions to specialist learning disability beds, the number to general
psychiatric beds and the totals for each year since opening.
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There is a highly significant upward trend in admissions of people with learning disability to general psychiatric beds (Pearson’s r=0.812, P=0.008). Comparison of the last 4 years with the first 5 shows a highly significant increase of admissions to these beds (independent samples t-test: t=11.11, P<0.001) with an associated decrease in admissions to learning disability specialist beds. The reduction in overall admissions is nonsignificant (P=0.105)
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Discussion |
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People with learning disability make up 2–3% of the UK population. (O’Hara, 2000). Both as children and adults, these individuals are at increased risk of developing severe mental illness and emotional disorder. Up to half will have significant mental health problems at some time in their life (Bregman, 1991; Hassiotis et al, 2000).
Adults with learning disability often have highly complex additional needs that cannot be met by current mainstream mental health services. (Bouras, 1999) The Government White Paper Valuing People (Department of Health, 2001) states that all people with learning disability should have access to community-based multidisciplinary healthcare, and it has also been suggested that appropriate in-patient treatment should be available when required (Scottish Home and Health Department & Scottish Hospital Services Committee, 1992; Holt & Joyce, 1999).
In the UK, specialist mental health services that can respond effectively to the needs of people with learning disability have now been developed (Lindsey, 2000). Such separate services should, however, not debar people with learning disability from access to mainstream mental health services if they would benefit from them. Indeed, part of the role of specialist learning disability services is to facilitate access to all mainstream healthcare, including mental health services (Hassiotis et al, 2000; Lindsey, 2002).
The Scottish Executive’s strategic review of services (Scottish Home and Health Department & Scottish Hospital Services Committee, 2000) estimated that, as long-stay hospitals are closed, 4 specialist assessment and treatment beds will be required for every 100 000 head of population. These beds should form part of a comprehensive learning disability service with appropriate community-based staff and resources to help minimise admission. Although the review recognises the need for specialist care, and acknowledges the likely increase in need for assessment and treatment beds, it suggested that much of it can be provided within non-healthcare settings and that access to mainstream services is an important part of the range of services available.
The present study looked at the period before and after the first closure of a long-stay learning disability institution in Scotland. Closure was complete in 1999 just prior to the publication of the strategic review. The population of Lothian is and was around 800 000 for which the review would predict a need for 32 specialist assessment and treatment beds rather than the 24 that exist. This might, in part, be a reason for the increasing numbers admitted to the general psychiatric hospital, but delayed discharges and increased pressure for admission of ‘new-to-service’ patients must also play major roles.
Although there is no conclusive evidence that specialist learning disability beds are better than general psychiatric beds for those with mild or moderate learning disability (Chaplin, 2004), a recent survey (Cooper et al, personal communication) carried out in response to the implementation of the strategic review revealed that 93% of learning disability services in Scotland believed that a dedicated learning disability assessment and treatment facility was the best option. The predominant opinion was that only those who had a mild learning disability and good communication skills and were not considered vulnerable would receive a better service in an adult general psychiatric ward. The proportion of patients with learning disability reported as having been admitted to an ‘inappropriate’ general psychiatry bed ranged from 4 to 57%. Some of these patients have to be transferred to a general psychiatry intensive psychiatric care unit because of their behaviour, which may be a reflection of their fear and inability to communicate verbally. As clinicians we believe that although there are a few patients with mild learning disability who may require the facility for risk of harm to self or others, usually in reponse to a psychotic episode, for most patients with learning disability a general psychiatry intensive psychiatric care unit is very inappropriate and can be detrimental. A total reliance on general psychiatric in-patient provision, which may be overstretched anyway, might therefore result in people with learning disability being denied access to appropriate or effective assessment and treatment. A total reliance on social care is also perhaps likely to endanger some patients who require more security or more medical expertise to understand and treat their illness.
Our study had a number of limitations. It was a retrospective case note study and depended on the accuracy of the information in the case notes. It is well known that the accuracy of such data cannot be guaranteed. However, the temporal changes presented here are clear: a reduction in the rate of admissions to specialised beds with an associated rise in admissions to general psychiatric beds. This change coincided with an increasing delay in discharging people both from acute learning disability assessment beds and learning disability rehabilitation beds. In the learning disability beds, at the end of 2003, 11 patients (46%) were regarded as having delayed discharges.
Additional evidence that general psychiatric services have not been available to absorb or manage all those patients with learning disability who require admission is perhaps seen in the recent growth in Scotland of private hospital capacity, particularly in the area of forensic learning disability beds, presumably in response to a shortfall in National Health Service (NHS) and social care provision for this group of patients. Interestingly Preibe et al (2005) show growing evidence of reinstitutionalisation in mental healthcare across many European countries. They comment that this is often in the form of forensic beds and they also worryingly point out the increasing numbers of prison placements, which we know from our own clinical work include some individuals with learning disability.
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Conclusions |
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Acknowledgments |
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References |
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BOURAS, N. (1999) Mental health and learning disabilities: planning and service developments. Tizard Learning Disability Review, 4, 3 –5.
CHAPLIN, R (2004) General psychiatric services for adults with intellectual disability and mental illness. Journal of Intellectual Disability Research, 48, 1 –10.[CrossRef][Medline]
DEPARTMENT OF HEALTH (2001) Valuing People: A New Strategy for Learning Disability for the 21st Century (Cm 5086). Department of Health.
HASSIOTIS, A., BARRON, P. & OHARA, J. (2000)
Mental health services for people with learning difficulties.
BMJ, 321, 583
–584.
HOLT, G. & JOYCE, T. (1999) Mental health and challenging behaviour services. Tizard Learning Disability Review, 4, 36 –42.
LINDSEY, M. (2000) Services for people with learning disabilities and mental health problems. Mental Health Review, 5, 5 –18.
LINDSEY, M. (2002) Comprehensive health care services
for people with learning disabilities. Advances in Psychiatric
Treatment, 8, 138
–147.
O’HARA, J. (2000) Learning disabilities
services: primary care or mental health trust? Psychiatric
Bulletin, 24, 368
–369.
PETERS, D. (1979) A Better Life: A Report on Services for the Mentally Handicapped in Scotland. Scottish Home and Health Department.
PREIBE, S., BADESCONYI, A., FIORITTI, A., et al
(2005) Reinstitutionalisation in mental health care: comparison
of date from six European countries. BMJ,
330, 123
–126.
SCOTTISH EXECUTIVE (2000) The Same as You? A Review of Services for People with Learning Disabilities. TSO (The Stationery Office).
SCOTTISH HOME AND HEALTH DEPARTMENT & SCOTTISH HOSPITAL SERVICES COMMITTEE (1970) The Staffing of Mental Deficiency Hospitals. TSO (The Stationery Office).
SCOTTISH HOME AND HEALTH DEPARTMENT & SCOTTISH HOSPITAL SERVICES COMMITTEE (1992) The Future of Mental Handicap Hospital Services. TSO (The Stationery Office).
WORLD HEALTH ORGANIZATION (1992) The ICD–10 Classification of Mental and Behavioural Disorders. Clinical Descriptions and Diagnostic Guidelines. WHO.
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  A. Mukhopadhyay and E. DaCosta Specialist learning disability psychiatry beds Psychiatr. Bull., December 1, 2007; 31(12): 468 - 468. [Full Text] [PDF]
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| British Journal of Psychiatry | Advances in Psychiatric Treatment | All RCPsych Journals |
