The future of the remaining NHS Inpatient Detox Units (IPUs) remains critically uncertain.
Funding cuts have meant that now as few as 6 NHS IPUs are operating in England and their funding remains precarious. An uncertain and unsustainable financial position has been created as a result of the 2012 Health and Social Care Act, which has seen reduced funding, alongside the current short-term, contracts being offered by Local Authority commissioners. Without change, the current challenges may lead to further closures across the remaining NHS IPUs, leading to devastating consequences for service users, their families and the wider healthcare system, as well as significantly impacting on community drug and alcohol services.
In the past, NHS IPU’s were part of regional collaborative commissioning arrangements.
Many are now struggling to survive due to a lack of block contracting arrangements. They are increasingly reliant on spot purchase admissions, often funded through frameworks on a bed night price which doesn’t account for the fixed costs of a highly skilled, professional workforce. This has seen decision making subject to localised tight gatekeeping based on finance, rather than clinical need.
Staff across NHS IPU’s are unhelpfully preoccupied with filling beds, in order to secure payments, with some frameworks only committing to paying for a bed which is actually occupied. This means all the risk sits with the provider in the event of a booked bed resulting in a “no show” or an unexpected early discharge, when there is no guarantee of filling the bed with an alternative admission.
What risk does this pose to those needing these services?
In the last three years, NHS IPUs have seen an increase in the number of patients admitted to their services and a significant increase in the level of acuity and complexity of the patients admitted. Patients are requiring increased levels of testing, engagement with in-house and allied health professionals, treatment and observation to support their detox alongside comorbid physical and/or psychiatric illnesses. NHS inpatient units are Consultant Psychiatrist-led and hospital-based, enabling the NHS units to manage the most complex patients which other, non-NHS services, often feel unable to support. Without access to IPUs, patients will not receive the care and treatment that they desperately need and this will result in an increase in premature death rates.
Up to 40% of patients with chronic alcohol dependence have some degree of cognitive impairment. NHS IPU’s see a high prevalence of patients presenting with impaired cognition. This is predominantly due to non-NHS units being unable to accept these referrals due to the challenges in managing the risk factors associated with cognitive impairment while going through the detox process, such as a history of seizures or the severe level of alcohol dependence. Some NHS IPU’s have access to neuro-psychological assessment, including psychometric testing, providing diagnosis and future management recommendations. This can sometimes result in the need to detain under the Mental Health Act, apply Deprivation of Liberties and source supportive, alternative accommodation on discharge.
Half of all patients admitted to NHS inpatient detox units have complex trauma, with many meeting the diagnostic criteria for post-traumatic stress disorder (PTSD) and experiencing symptoms such as flashbacks or nightmares. Due to this, a trauma-focused approach to care is undertaken across the workforce and the environment, often led by psychology colleagues. This strong multi-disciplinary team, evident across NHS IPU’s which also includes nursing, social work, pharmacy and other professionals, such as physio, dietitians and physicians, describes their unique importance within the treatment system. This expertise, which includes ongoing contributions to the medical training programme, is at significant risk within the current budgetary and commissioning arrangements.
How might funding cuts impact the wider healthcare services and addiction treatment services?
Further funding cuts and closure of NHS IPUs would lead to a high risk of increased admission rates, re-admissions and length of stay to other healthcare facilities, including the acute hospital sector and mental health inpatient units For example, in Kent, 25% of re-admissions to inpatient psychiatric facilities are judged to be mainly or solely due to untreated substance use problems. Currently, across some mental health inpatient units, substance misuse issues are reported to be a factor in more than 50% of delayed transfers of care and/or discharges. Nationally, there are more than 20,000 admissions to acute hospitals each year due to alcohol-related liver disease.
An absence of change will ultimately lead to less inpatient detox units and therefore poorer outcomes for community substance use treatment providers, requiring them to manage highly complex, comorbid patients in the community, bartering with colleagues in the acute sector to support detox options as the only “inpatient” option. Complex patients that do not receive the treatment modality they need, will reach crisis, often presenting at A&E services, thus impacting on Clinical Commissioning Groups’ budgets.
Without secured funding for NHS IPUs to continue to manage and treat the most complex and acute patients who other services are unable to manage, there will be an increase in the number of drug and alcohol related deaths.. Without secure funding there is not only a significant risk to patients, but also the likelihood of a huge burden being placed upon the wider healthcare system, other drug and alcohol services and society as a whole.
As well providing essential care for some of the most vulnerable and disadvantaged members of society, the NHS IPUs also offer unique training and development opportunities for health and social care students and medical staff. Students cannot get medical training in alcohol and substance use detox and rehabilitation anywhere else, meaning that IPUs are the only places in England to train staff who enter this field of medicine. Without these services there would be a significant deficit in the number of staff who are suitably trained and experienced to respond to the needs of those with severe alcohol and substance misuse problems.
How does the Dame Carol Black Review [2019] support the case for maintaining NHS IPUs?
Disinvestment in the sector is highlighted in the Dame Carol Black part one report, which shines a spotlight on how budgets for substance misuse services have been significantly reduced over recent years. Local Authorities, who hold the responsibility for commissioning local substance misuse services, across all modalities, are now faced with no other option than to focus the funding that they receive on community services, rather than funding the IPUs.
The Dame Carol Black report also confirms that “a prolonged shortage of funding has resulted in a loss of skills, expertise and capacity from this sector”. This is particularly true for NHS expertise in the form of Consultant Addiction Psychiatrists, Clinical Psychologists and Registered Nurses, the report noting “the number of training places for addiction psychiatrists has plummeted from around 60 to around 5, meaning there is no capacity to train the next generation of specialists”.
The part one report clearly indicates that funding cuts have already had a detrimental impact on the sector and that we must prevent any further cuts to services.
What can be done to ensure that NHS IPUs do not face further funding cuts/eradication?
The NHS APA and NHS Inpatient Network believe that due to the acute nature of the clinical services provided to patients who have diverse and complex mental and physical health needs they pose compelling similarities to other regional Tier 4 services that are directly commissioned by NHS England. For example, Specialised Perinatal Mental Health Inpatient Services (Mother and Baby Units), Tier 4 CAMHS and Adult Forensic Inpatient Units. The similarities between the mental and physical health needs of these patients as well as the models of clinical interventions delivered in comparison to that of the NHS IPUs is striking. The high cost, low volume activity, lends itself to a collaborative commissioning approach, often nationally specified and regionally commissioned.
The NHS APA and NHS Inpatient Network recommend that the commissioning arrangements for NHS IPUs are changed to allow NHS England to directly commission and fund all existing NHS Inpatient Detox Units under a single specification in line with similar Tier 4 specialist services. The APA and Inpatient Network believe there would be substantial improvements to patient care planning and interventions if NHS IPU’s were directly commissioned and funded in this way, preventing the continued erosion of this specialty under the current localised commissioning arrangements.
Summary
It is hard to think of another area across healthcare where similar models of contracting and commissioning are applied, including the self-defined categorisation of whether or not a non-NHS provider is “medically managed” or “medically monitored”. These descriptors, originally introduced by the Specialist Clinical Addiction Network (SCAN) in 2006, were subject to scrutiny and consistency by the National Treatment Agency. Since their absorption into Public Health England in 2013, there has been no national oversight of Tier 4 services. The Care Quality Commission reported in 2016/17 that they had taken action against 72% of residential drug and alcohol detoxification providers, due to breaches in the Health and Social Care Act.
The current challenges faced by NHS Inpatient Units means their future remains uncertain. In addition to the risks to patients and the wider NHS, this uncertain future is contributing to a loss of highly qualified, professional, experienced staff, with significant difficulties in recruiting. The closure of units is reducing the number of training posts available and the expertise to train the substance use treatment experts of the future. Likewise, lack of capital investment is resulting in the deterioration of the physical infrastructure of existing units meaning they will, in time, become unfit for purpose. It is imperative that we act now to secure funding for NHS IPUs to guarantee their survival.