Title: Assessing the Clinical and cost-Effectiveness of inpatient mental health Rehabilitation services provided by the NHS and independent sector (ACER)
Funder: Department of Health and Social Care

Abstract: Mental health rehabilitation services provide specialist treatment to people with particularly severe and complex problems. These services include inpatient units and supported accommodation in the community. When people have access to local rehabilitation services, most gain the skills to manage with less support over time, progressing from inpatient care to higher, and then lower, supported accommodation. However, the last 15 years or so have seen major cuts to NHS rehabilitation services across England and increasing reliance on the independent sector. The Care Quality Commission reported in 2018 that over half the 4400 mental health inpatient rehabilitation beds in England were provided by the independent sector. They raised concerns that people were staying twice as long compared to people treated in NHS rehabilitation units, doubling the costs of care and they were much further from their home. This has been criticised in the press and influenced a national initiative by NHS England (‘Getting It Right First Time’) to encourage Clinical Commissioning Groups to invest in local NHS rehabilitation services. However, we do not know whether the services provided by the NHS and independent sector differ in quality or patient outcomes. Reversing the current situation risks wasting the rehabilitation expertise gained by the independent sector and major investment may be needed to rebuild local NHS services. It could also be that NHS Trusts send their most complex individuals to the independent sector as their needs cannot be met locally and that is why they stay in hospital longer. _x000D_ _x000D_ There have been no studies investigating the effectiveness of inpatient rehabilitation services that have included the independent sector. Our study aims to address this gap. _x000D_ _x000D_ As we cannot compare NHS and independent sector services through a randomised trial, our programme will draw together findings from five components to assess the effectiveness of these services_x000D_ 1) Survey of 60 inpatient mental health rehabilitation services across England (30 NHS and 30 independent sector) _x000D_ 2) In depth interviews with users, relatives/carers, staff and commissioners of these services to explore their experiences and perspectives _x000D_ 3) Cohort study to compare outcomes for 500 patients of the NHS and independent sector rehabilitation services surveyed in Component 1, using statistical methods to take account of any differences between them such as the severity of their mental health problems _x000D_ 4) Comparison of outcomes for all users of NHS and independent sector inpatient rehabilitation services in England on a specific census date, using anonymised electronic NHS records _x000D_ 5) Health economic evaluation to assess the cost effectiveness of inpatient rehabilitation services provided by the NHS and the independent sector_x000D_ _x000D_ In components 3, 4 and 5, our outcome is ‘successful rehabilitation’ at 18 months follow-up i.e. being discharged from inpatient rehabilitation services to the community without readmission._x000D_ _x000D_ Our results will be relevant to people who require rehabilitation services and their families and they will help commissioners and providers decide how best to deliver services. Our methods could also be used in other areas of the health service that use the independent sector. We will share our findings through our study website, journals, conferences, webinars and social media and recommend appropriate changes to practice to the relevant national bodies.

Lay abstract: Background_x000D_ Mental health rehabilitation services provide specialist treatment to people with particularly severe and complex problems. Over recent years there have been major cuts to NHS rehabilitation services across England and increasing reliance on the independent sector. In 2018, the Care Quality Commission reported that over half the 4400 mental health inpatient rehabilitation beds in England were provided by the independent sector. They raised concerns that the length of stay and cost of independent sector care was double that of the NHS and tended to be provided much further from people’s homes. This influenced a national initiative by NHS England (‘Getting It Right First Time’) to encourage Clinical Commissioning Groups to invest in local NHS rehabilitation services. However, we do not know whether the services provided by the two sectors differ in quality or outcomes. It could be that NHS Trusts send their most complex individuals to the independent sector as their needs cannot be met locally, hence the need for longer admissions; it may also be that longer admissions result in better outcomes. Alternatively, patient characteristics and outcomes may be similar for the two sectors, suggesting that the current situation represents an inefficient use of public resources. There have been no studies investigating the effectiveness of inpatient rehabilitation services that have included the independent sector. Our study will address this gap._x000D_ _x000D_ Aim and objectives_x000D_ We aim to investigate differences in inpatient mental health rehabilitation provided by the NHS and independent sector in terms of: patient characteristics; service quality; patient, carer and staff experiences; clinical effectiveness and cost efficiency._x000D_ _x000D_ Methods_x000D_ As it is not possible to compare the two sectors through a randomised trial, our project will triangulate findings from five components. The first two are descriptive and the latter three use epidemiological methods to estimate clinical effectiveness and cost efficiency: _x000D_ 1) a survey to compare the quality of services and patient characteristics involving 60 inpatient mental health rehabilitation units across England (30 provided by the NHS and 30 provided by the independent sector) and 500 patients_x000D_ 2) an in-depth qualitative investigation of patient, family, staff and service commissioners’ experiences and perspectives on inpatient mental health rehabilitation provided by the two sectors_x000D_ 3) a cohort study comparing clinical outcomes in the two sectors for the 500 patients recruited in Component 1, using four related regression analyses that take account of differences in patient characteristics_x000D_ 4) a prospective study comparing clinical outcomes in the two sectors for all users of inpatient rehabilitation services in England on a specific census date, using instrumental variable analysis of anonymised electronic NHS records _x000D_ 5) a health economic evaluation comparing the costs and cost efficiency of inpatient rehabilitation services provided by the NHS and the independent sector using data from Components 1, 3 and 4._x000D_ _x000D_ In Components 3, 4 and 5 our outcome for comparison of NHS and independent sector services is ‘successful rehabilitation’ i.e. being discharged from an inpatient rehabilitation unit without readmission over the following 18 months. _x000D_ _x000D_ Our methods could also be used to evaluate other areas of the health service that use the independent sector.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: MENTAL HEALTH