The introduction of NHS England’s Transforming Care agenda in 2012 presented significant challenges for commissioned providers of long-stay in-patient facilities for people with learning disabilities and/or autism.
Magnifying these challenges, and the need for radically revised care strategies in the sector, were the significant reductions of in-patient capacity mandated by Building the right support, the NHS commissioning plan published in October 2015.
This document outlined a national service model to ensure that Transforming Care delivered on its goal of improving health and care services so that more people with learning disabilities could live to their full potential in the community, with the right support, and close to home.
Re-integrating patients into the community as swiftly and seamlessly as possible, while ensuring they are properly equipped to make what for many will be a difficult transition, means reconfiguring services and embracing new ways of working across a broad range of parameters.
These include care pathways, staff expertise, facility design, managing challenging behaviour, relationships with other providers to facilitate re-integration, and the involvement of families, carers and patients in shaping service delivery.
Demanding though these changes are, they have encouraged care providers to think creatively about how people with learning disabilities who need specialist inpatient care can break what is all too often a dispiriting cycle of admission, extended stays, discharge and re-admission
Among the key mandates of Building The Right Support was that no area of England would need capacity for more than 10-15 inpatients with learning disabilities per million population. Where patients did require more specialised support in-house, their length of stay should be as short as possible. This effectively meant that 25-40% of NHS England-commissioned capacity and 35-50% of inpatient provision would have to close nationally, with alternative care provided in the community.
The impact was even more significant in areas of the country more reliant on inpatient care. That included the West Midlands, where the deadline for implementation of the national service model introduced with Building The Right Support moved forward from March 2019 to March 2018.
This model set out a range of services and support mechanisms around nine core principles, such as:
- Making sure care and support for people with learning disabilities is person-centred, planned, proactive and co-ordinated.
- Giving them choice and control over how their health and care needs are met, as well as where they live and who they live with.
- Providing patients with access to specialist health and social-care support in the community
- Limiting hospital stays and ensuring high-quality services when patients are admitted for assessment and treatment in that setting.
Ashley House to Eldertree Lodge
Within the Huntercombe Group (THG), the standard-bearer for Transforming Care in practice has been Eldertree Lodge, a High Dependency Inpatient Rehabilitation Service for people with Learning Disabilities in Market Drayton.
The service provides rehabilitation and support for adults with learning disabilities who have been in long-stay environments, or who find themselves suddenly unable or unprepared to cope with living in the community.
Eldertree Lodge was previously known as Ashley House Hospital, a low-secure inpatient service for adults with a primary diagnosis of learning disability.
Aligning facilities and practices at Ashley House Hospital with these principles called for a fundamental overhaul of the existing service model, as well as new relationships with community care providers to make sure re-integration occurred in the right way and at the right pace.
To reflect these changes, Ashley House Hospital rebranded to Eldertree Lodge, offering innovative high-dependency rehabilitation services. Ward sizes were reduced to 6-8 beds maximum, with new purpose-built de-escalation suites on each admission ward. The revised layout, spread over six units, improved staff-to-patient ratios while more closely approximating future community living and recognising that people with learning disabilities cope better in familiar environments with fewer residents and less noise.
Two revised patient pathways were launched: a Male Neurodevelopmental Pathway and a Female Complex Care Pathway, both geared to moving patients back into their home, the community or, at a minimum, a step-down environment as soon as possible. This step-down approach was replicated within Eldertree Lodge, with patients transitioning from a tailored short-stay (3-6 months) admission service to a matching pre-discharge service (6-9 months).
Historically, Ashley House Hospital had performed significantly above the national average on discharge rates: 15 months versus an average stay of 31.6 months nationally. With the reconfiguration of services at Eldertree Lodge, along with newly aligned teams and care pathways, the average length of admission to discharge reduced to 12 months or less.
At the same time, an accelerated pathway created the need for new services that would enable patients to re-integrate into the community as smoothly as possible and avoid unnecessary rehospitalisation.
In alliance with Arch, part of the Staffordshire Housing Group, Eldertree Lodge is developing an end-to-end care model that includes a Supported Living environment, a step between pre-discharge and independent living.
This comprises apartment style accommodation in the community, backed up by outreach support from the Eldertree Lodge team.
A new Positive Behaviour Support Emphasis
A crucial element in delivering person-centred, proactive care at Eldertree Lodge was the adoption across THG of Positive Behaviour Support (PBS) strategies. PBS aims to enhance quality of life by encouraging positive alternatives to challenging behaviour, rather than simply repressing behaviour through restrictive interventions.
To date, we have nine PBS coaches, two practice leaders and a number of practitioners at Eldertree Lodge, while around 80% of the staff have received Introduction to Positive Behaviour Support training.
The impact has been significant, both on the volume of challenging incidents and the need for physical interventions. A recent cohort study of PBS outcomes at Eldertree Lodge found there had been a 37% reduction in restraints since the PBS programme was implemented.
A Refreshed Community Focus
We have also introduced a stronger community focus into our services, so that we can equip patients with as many skills as possible to help them integrate and live independently following discharge.
These include educational opportunities, such as horticulture courses or placements in an animal-care college; the onsite Ash Tree Café, run by patients with support from the occupational-therapy team to facilitate vocational rehabilitation and social inclusion; and music therapy in partnership with Nordoff Robbins.
Another facet of boosting patients’ engagement and autonomy to prepare them for independent living is involving them in all levels of service delivery at Eldertree Lodge, such as attending governance meetings or auditing health and safety issues.
A family and carer forum helps these key stakeholders influence services in ways that will support them in accommodating the patient’s return to the community. Approved patient access to digital communications through mobiles or tablets is one other means of easing the transition.
Developing a Best-practice Model
Faced with the tough demands of the Transforming Care agenda, Eldertree Lodge has reconstructed and rejuvenated its service model to offer patient-centred rehabilitation with re-integration into the community at its core.
It has done so without any reduction in staffing, and with only a minor reduction in patient capacity to accommodate the facility redesign.
As a model for best practice within THG, we are now working with other hospital managers to help them implement the learnings from Eldertree Lodge and establish Transforming Care as the foundation of inpatient provision for people with learning disabilities across the Huntercombe network.
By Alan Malin, Hospital Director, Eldertree Lodge
 Building the right support. A national plan to develop community services and close inpatient facilities for people with a learning disability and/or autism who display behaviour that challenges, including those with a mental health condition. NHS England. October 2015. Retrieved from https://www.england.nhs.uk/wp-content/uploads/2015/10/ld-nat-imp-plan-oct15.pdf.
 Supporting people with a learning disability and/or autism who display behaviour that challenges, including those with a mental health condition. Service model for commissioners of health and social care services. NHS England. October 2015. Retrieved from https://www.england.nhs.uk/wp-content/uploads/2015/10/service-model-291015.pdf.