High cost placements Peter McGill and Jo Poynter

Background Discussions within NSG steering group about cost issues High cost of some placements a potential driver for the development of different models Mansell report commented on the need to redirect resources from expensive out of area placements

Previous work Little previous work Hassiotis et al (2008) – Survey of high cost placements (over 70k) in 5 London boroughs for people with LD/CB – 205 placements identified, 65% of them out of area – Majority male and with moderate/severe LD – Health/sensory/mobility problems common – Nearly a third with autism – Over 10% with mental health diagnosis

Previous work (contd) Hassiotis et al (2005) (contd) – Service users out of area Had more severe cb Were younger – hospital (private/nhs) most expensive – Overall, out of area placements slightly more expensive (106k vs 98k) and had higher CSCI scores

Questions/suspicions Most high cost placements out of area? Most for people who present challenging behaviour? Most in traditionally organised care? Significance of offending/mental health issues? Significance of other individual characteristics? Variation across areas?

What we did JP ed all (19) local authority commissioners in SE Region Asked for information about their 5 highest cost placements: – Cost – Gender, age – Nature of disability – Nature of placement – Plan, discharge date – In/out area

What we did (contd) After a reminder from PM 14 areas provided information about 70 placements Some information missing or very limited despite follow-up seeking more detail

Findings - cost Mean £172k, Range £83-£333k Substantial variation in mean cost across authorities from £98k to £250k Some evidence of clustering of costs within authorities

Findings – gender, age Gender – 51 male, 19 female (130:75 in Hassiotis) Age – mean of 33 years, range (36 years in Hassiotis)

Findings – nature of disability Note well, limited data Autism – 23% Physical/health needs – 13% Challenging behaviour – 46% Mental health needs – 11% Severe ld – 16% Mild/moderate ld – 27% Offending behaviour – 7% Specific syndrome – 7%

Findings – nature of placements Type of placementPercentage Hospital or other secure/treatment20% Residential care61% Residential college4% Supported living or similar14%

Findings – plan, discharge date, in/out area Plans for individuals were reported in 54% of cases Discharge dates were reported in 3% of cases 71% of placements were out of area

Differences between in and out of area placements People placed out of area significantly more likely – To be male (80% vs 55%) – To be in residential care (72% vs 35%) – Not to be in supported living (2% vs 45%) No significant differences in cost, age, other individual characteristics, other placement characteristics

Predictors of higher costs Hospital or similar placements (£219k vs £161k) Challenging behaviour (£190k vs £157k) Syndrome (£223k vs £168k) (SMS mentioned twice)

Summary Problem of inadequate/missing data Average cost of £172k, wide variation Individuals are mainly male, young with high prevalence of challenging behaviour and autism Mixture of people with mild vs severe ld 3/5 th s of placements residential care, 1/5 th hospital or similar

Summary contd Most placements out of area with limited evidence of planned changes Out of area placements more likely to be residential care for males High cost associated with hospital placements, challenging behaviour and individual having identified genetic syndrome

Implications/issues for discussion Possibly some evidence of innovative local developments Still lots of high cost, out of area placements with very limited evidence of plans to change this Area differences may reflect many things including natural variation in low incidence characteristics Pattern of individual characteristics perhaps draws attention to service deficits