Learning Disability Services, Gloucestershire Partnership NHS Trust, UK
Correspondence: Dr Bunny Forsyth, Heathfield, 30 Denmark Road, Gloucester GLI 3HZ, UK. E-mail: bunny.forsyth{at}blueyonder.co.uk
B.F. & P.W. work for Gloucestershire, a rural county.
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ABSTRACT |
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Aims To compare expenditure on learning disability health services across England with the burden of services regionally, as estimated by numbers of people with learning disabilities.
Method A national database was set up using data from the National Audit Commission and the Department of Health. The spend/burden ratio was calculated and correlation tests for likely causes of inequality were applied.
Results There is widespread discrepancy from the median spend/burden ratio of £10260 per person with learning disability. There is a positive correlation between ratios and levels of net exports of people funded by their local authority social services to resideout of area. Comparative underspending occurs in rural areas.
Conclusions There are inequalities in levels of spending on learning disability services. Comparison of regions suggests resources may not be allocated fairly. Health authorities should ensure that population increases are mirrored by appropriate adjustments in expenditure.
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INTRODUCTION |
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Specialist residential care provision in some regions has allowed people with learning disabilities to be funded by their local social services to reside out of area if similar local provision is not possible. If there are ongoing mental health needs, these should theoretically be funded by payment from the original health authority to the out of area health authority through a service level agreement. This should compensate for any extra burden on health services in receiver areas. We suspect that this often does not happen.
Allocation formulas do not address the specific needs of the population with learning disabilities. Inherent difficulties in fair allocations and the need for better research are well recognised (Judge & Mays, 1994). We tackle this complex issue by ascertaining the correlation between health authority spending and the overall burden on learning disability services regionally.
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METHOD |
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Calculation of the total burden
This calculation aimed to ascertain the total number of adults with
learning disabilities residing within each health authority area. The relative
levels of specialist service need and socio-economic or demographic variables
were not addressed.
Data were obtained from the community care statistics published by the Department of Health (2000), for all adults aged 18 years and over with learning disabilities. This total gave the number of adults with learning disabilities in registered homes; these included residential, dual-registered (although excluding general adult mental health placements), small (three people or fewer), voluntary, private, local authority social-service-funded and nursing home establishments. Figures were verified by approaching three health authorities directly and comparing these totals with the lists of individual establishments. Hospital and prison populations were excluded. In addition, Department of Health information was used to obtain the numbers of adults with learning disabilities helped to live at home (Department of Health, 1999a). This included those accessing any form of help from social or health services such as welfare benefits, but specifically excluded people in residential care, to prevent double counting. These figures were added to give the total burden: the approximate number of all adults with learning disabilities resident in that region. An estimate of the prevalence of learning disabilities was calculated by expressing the total burden as a percentage of crude population figures.
Calculation of the spend/burden ratio
The total expenditure on learning disability services for each health
authority was divided by the total burden for the same region to give a
spend/burden ratio, a tool devised for the purpose of this research. Expressed
as a formula, this is
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As the data were not normally distributed, we calculated the median value of the ratios to prevent results skew by extremes. The ratios of the individual health authorities were compared with this figure; a ratio significantly less than the median value suggests comparative underspending.
Confounding factors
Potential confounding factors that might have influenced results were
associated with the following factors.
Spearman's rank correlation was used to assess positive or negative correlation between the spend/burden ratio and long-stay data, comparator grouping, or percentage of local-authority-funded placements.
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RESULTS |
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Total health expenditure on learning disability services ranged from £2 864 000 (Herefordshire) to £63 751 000 (East and West Surrey). The total burden ranged from 273 (Stockport) to 3839 (Lancashire). The spend/burden ratio varied from 4.23 (Lincolnshire) to 27.99 (Stockport), the median being 10.26 (£000 per person with learning disability). Figure 1 contrasts the ten regions with the highest, middle and lowest rankings.
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The health authorities were grouped by comparator data, e.g. all regions classified as growth areas. Spend/burden ratios showed no correlation, having randomly high or low values within these groupings (Fig. 2). Health authority spend/burden ratios were then compared with the percentage of local-authority-funded placements. This relationship had a statistically significant positive correlation (Spearman's rank correlation, two-tailed, 0.413, P < 0.001). Net exporters (with values greater than 100%) were seen in increasing numbers as the spend/burden ratio increased. There were none in the ten lowest-ranked authorities, one in the middle-placed and five in the highest-placed regions (Fig. 3). Numbers of long-stay hospital placements (which would not register in other residential figures) showed no correlation with spend/burden ratios (Spearman's rank correlation, two-tailed, -0.113, P=0.31).
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Verification of figures
Verification of the accuracy of Department of Health registrations data was
attempted by approaching three health authorities directly, namely South
Gloucestershire, Bristol and Hampshire, who provided detailed lists of all
residential establishments in their region, together with the population
figures for each home. These figures were added together, then divided by the
Department of Health figure to express a positive or negative percentage
deviation. There was a deviation in numbers of 2.5% (485/473), -5.1% (788/830)
and -3.6% (1036/1075) respectively. This suggests a maximum margin of error of
5%.
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DISCUSSION |
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The data used to calculate the total burden were derived from social services, and there may well be regional differences in the accuracy of the figures obtained. However, there is no other available source of such data at present. We must assume the accuracy of the data collected but there is no independent means of validation.
Excluded categories
A section of the population with learning disability is, by definition,
excluded from this study; these are adults with learning disabilities who live
at home alone or with their families and do not receive any form of help from
health or social services, including welfare benefits. To include this group
was beyond the means of this study. A larger group of people with mild
learning disabilities (IQ=55-69) living independent lives and not identifying
themselves as having disabilities are also excluded.
The IQ test with mean 100 (s.d. 15) is normally distributed in populations, giving a predicted 2.27% of the population falling below IQ=70 (used to define learning disability). However, there is also a small effect below IQ=50 from specific pathological conditions. Some data confirm these figures (Rutter et al, 1976; Szymanski & Kaplan, 1997). However, the percentages identified in other prevalence studies of 0.3% to 0.65% (Fryers, 1993; Van Schrojenstein Lantman-De Valk, 1997) correlate with the figures obtained here, illustrating the difficulty of including all who qualify. Few reliable sources for prevalence estimation exist because of varying selection criteria and case-finding methods, as well as variations in age and in temporal and social factors (Fryers, 1997).
Financial complexities
Unusual forms of purchasing arrangements can cloud accurate spend figures.
There are funds known as Section 28 transfers, which allow the
movement of funds from health authorities to local authorities. These are
applied to people who were resident in long-stay hospitals before April 1971.
This money follows the individual until movement out of National Health
Service (NHS) care or death, and counts against health authority expenditure.
Owing to the complexity of care provisions, with different health authorities
making different arrangements for the continuing care of former asylum
residents, exact expenditure has become difficult to untangle. Other funds,
not tied to individuals, may also count against spend; these are now under
investigation by the Department of Health.
Further complication may arise from health authorities using health funds to provide what is effectively social care, funding which should be provided by social services. Old long-stay beds are an example for which we have accounted, but other residential placements of people with high-level needs may have a percentage of their specialist residential care paid for by the health budget. The definitions for these provisions and standard percentage contributions for such cases may vary across the country, and we have no means of tracking them individually.
Provision for autism and children's services
A further complicating factor is that of provision for children with
learning disabilities. Although spend figures are supposed to represent adult
expenditure only, there are very different practices across England in how
child and adolescent mental health services liaise with learning disability
services. In addition, some regions provide services for autistic-spectrum
disorder under the learning disability services umbrella, whereas others do
not. This could well be mirrored by different financial arrangements allowing
for transitional services and dual working.
Differences in spend/burden ratios
There appear to be large discrepancies nationally in the spend/burden
ratios, with some health authorities spending far less on services in relation
to the number of people with learning disabilities than do others. This study
makes no attempt to define adequate levels of spending, merely to make
comparisons with a national median. Whether there is national underresourcing,
adequate resourcing or even overresourcing, the emerging picture strongly
suggests a widespread disparity between health authorities. It is important to
remember that high spending does not necessarily equate with effective use of
resources, and that lower relative expenditure may represent more efficient
and effective services. Although the quality and costs of residential
provision for people with learning disabilities have been investigated
(Hatton et al, 1995; Department of Health,
1999b), comparison of spending levels with respect to
population numbers has not been reviewed.
Regional differences
Clarification of data enabling analysis of confounders such as comparator
grouping does not seem to explain the spend/burden ratio discrepancies.
However, in looking for regional patterns the results show more rural areas
with lower expenditure relative to higher burden.
Exporter v. receiver areas
There is significant correlation between spend/burden ratios and the
proportions of placements funded by local authority social services. Given the
rarity of privately funded placements, results suggest that lower-ratio health
authorities (receiver areas) have more imported placements from
other regions. Higher-ratio health authorities are significantly more likely
to be net exporters. It is notable that all clear exporter health authorities
are smaller, urban regions. It may be that it is the geographical size of the
region rather than the urbanrural distinction that increases the
likelihood of export, with smaller authorities having fewer internal
residential resources. It may be cheaper to build residential facilities in
rural areas than in cities, and this too could account for greater use of
exports to rural regions. Out of area placements are often used
where higher levels of specialist services are needed (implying greater health
needs). Unless service level agreements are arranged with the receiving health
authority, the receiver area funds any future mental health needs. In effect,
this can mean that the health burden of such placements is particularly high,
this being the experience locally in Gloucestershire. There is an implication
that accurate enforcement of service level agreements for all exported people
with specialist mental health needs might redress the imbalance of present
expenditure patterns. If this is unworkable, overhaul of present allocation
methods may be necessary.
Although recent research has looked at the extent of out of area admissions to psychiatric beds in general psychiatry (Glover & Bindman, 2001), there is no similar research in the learning disability sector, either for hospital or residential out of area placements.
Long-stay hospital data
The lack of correlation between numbers of long-stay (asylum) placements
and spend/burden ratios is surprising, given that these figures would be an
obvious source of discrepancies.
Clinical implications
Effect of asylum closure
The fact that expenditure on learning disability services is not
distributed equitably between health authorities mirrors the findings of
research into general mental health service expenditure
(Bindman et al, 2000).
The noted high level of expenditure on general mental health services in
London (Chisholm et al,
1997) has been attributed to need greater than that accounted for
by the York index (Ramsay et al,
1997). Whether this translates into spending on learning
disabilities services is unknown. Crucially, the movements of this vulnerable
population over the past decade as asylums have closed have not been accounted
for in a coherent national approach with regard to relative levels of
expenditure. This has created ethical dilemmas
(Greaves, 1997).
This study suggests that the export of people out of their home county has not been paralleled by an increase in spending by the receiving counties facing the consequent higher burden. The closure of asylum provision may therefore have occurred at the expense of such receiver areas without adequate follow-through of finances to fund the needed community care.
Political initiatives
The impact of political initiatives on spending is not documented in
learning disability research. The formation of health action
zones in areas such as Stockport and Sandwell may have affected their
expenditure. Similarly, some areas have pioneered effective joint working
between health and social services, as has been done in Hillingdon, and this
may have had a beneficial effect on improving the efficiency and profile of
the service area.
The White Paper Valuing People: A New Strategy for Learning Disability for the 21st Century (Department of Health, 2001) sets out proposals for improving the lives of all people with learning disabilities. A new learning disability development fund of £22 million revenue and £20 million capital is being introduced in 2002, to ensure implementation. The observed discrepancies suggest that individual health authorities should address potential inequalities, particularly in the light of future budgetary increases, to ensure that people with learning disabilities are optimally and equitably served.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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REFERENCES |
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Received for publication November 21, 2001. Revision received April 3, 2002. Accepted for publication April 5, 2002.
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