Transforming Care: How to Commission for Better Long-Term Outcomes

Transforming care isn’t about ticking policy boxes; it’s about changing lives. At Gray Healthcare, we believe better long-term outcomes begin with strategic commissioning that puts people first. Whether dealing with learning disability, mental health conditions, or acquired brain injury, the right health and care services for individuals with complex needs must prioritise building independence, resilience and community support.

In this article, we explore how effective commissioning and recent outcomes can reshape the health and social care system, driving long-term improvements for people with complex needs.

The National Imperative: Learning Disability & Mental Health

The scandal at Winterbourne View hospital in 2011 marked a turning point in how the UK approaches the care of people with a learning disability and/or autism. The subsequent Department of Health report, Transforming Care: A National Response to Winterbourne View Hospital, called for urgent reforms to prevent such abuses from happening again. The Winterbourne View Concordat followed, with signatories, across health and care bodies, including the Care Quality Commission (CQC), committing to a system-wide change.

A Timeline of Transforming Care Policy Milestones

Several key publications have since shaped the direction of the Transforming Care Programme, including:

• 2014 – Time for Change: Called for expanding community services and stronger commissioning.
• 2015 – No Voice Unheard, No Right Ignored: Highlighted the dangers of placing people far from home in inappropriate settings.
• 2015 – Building the Right Support: A national plan from NHS England, the Local Government Association (LGA), and the Association of Directors of Adult Social Services (ADASS) to reduce inpatient beds and grow community-based alternatives.
• 2016 – Building the Right Home: Guidance on expanding housing options for autistic people and those with learning disabilities.
• 2019 – NHS Long Term Plan: Committed to halving inpatient care levels and improving community support services.
• 2021 – 2026 – National Autism Strategy: The Department of Health & Social Care and the Department for Education introduced a five-year strategy aiming to improve health, education, and social care for autistic people and children. Key themes include inclusion, early detection and transforming support within communities.
• 2021 – People at the Heart of Care: Adult Social Care Reform White Paper: This landmark white paper outlined a 10-year vision to transform adult social care in England, emphasising the key principles of choice, independence and investment in community care, housing and the workforce.
• 2022 – ‘Building the Right Support’ Action Plan (Updated): This updated action plan refined the aims from the original 2015 document – focusing specifically on community-based support to reduce mental health inpatient reliance among those with learning disabilities and autism.
• 2022 – Health and Care Act: This landmark legislation reinforced integration across health and social care, strengthening the foundations of the NHS Long Term Plan and enabling more collaborative commissioning of community services.
• 2024 – Regulatory Demand: Oliver McGowan Code of Practice: Named in memory of Oliver McGowan, this mandatory training and code of practice sets legal standards for the competencies of care providers in supporting people with a learning disability and autistic individuals – aiming to close the gap in health inequalities.
• 2024 – Continued LeDeR Expansion: The NHS broadened the LeDeR (Learning from Deaths Review) programme to include autistic people, providing deeper insight into avoidable deaths and health inequalities and guiding service improvements.
• 2025 – Legislative Reform: Mental Health Bill: These proposed reforms aim to remove autism and learning disability as grounds for detention under Section 3 of the Mental Health Act 1983 – a move intended to protect individuals’ rights and limit unnecessary hospital stays.

Each of these policies stresses a shift away from institutionalisation towards independent, community-based living, placing emphasis on dignity, choice and personalised care.

Where Are We Now?

Despite these ambitions, progress remains slow. The most recent Assuring Transformation (AT) data by NHS England (July 2025) reveals that:

• 2,010 people with learning disabilities and/or autism are still in inpatient services.
• 50% of these individuals had been in hospital for over two years.
• 1 in 4 people with a learning disability or autism are readmitted to hospital within a year.

These figures highlight a stark reality: despite national policy and investment, too many individuals remain in restrictive settings for far too long. The data points to a system that still struggles to deliver on the promise of community-based care, underlining the urgent need for better commissioning, stronger care partnerships, and scalable, person-centred solutions.

Out-of-Area Placements: A Persistent and Growing Concern

Out-of-area placements (OAPs) remain a serious concern, particularly for those with acute mental health needs. A 2023 analysis by the Royal College of Psychiatrists found that more than 5,000 people were sent over 100km from their registered home in England between April 2021 and March 2023, despite a 2016 government commitment to end this practice by 2021.

Cracks in the Care Framework: Why OAPs Continue

Far from being phased out, inappropriate OAPs are on the rise again. The Health Services Safety Investigations Body (HSSIB) reported in November 2024 that such placements remain prevalent because of persistent shortages in local beds, underinvestment in community services and a lack of specialist staff. The British Medical Association (BMA) has also recently echoed concerns that efforts to reduce Out-of-Area placements has plateaued.

The Human Cost of Being Sent Away

Out-of-Area placements are not just a logistical issue – they are deeply harmful. Being treated far from home disconnects individuals from the very networks that are essential to their recovery: family, friends, and local professionals who understand their history and needs. Research by the Health Services Safety Investigations Body (HSSIB) has linked distant placements with increased distress, incidents of PTSD and even suicides. The Royal College of Psychiatrists has echoed these concerns, warning that such placements not only delay recovery but also heighten the risk of self-harm and place significant financial strain on the NHS, costing over £120 million annually.

Health Inequalities: What the LeDeR Reviews Reveal

The LeDeR (Learning from Deaths Review) programme continues to expose entrenched inequalities. The 2019 report highlighted that:

• People with profound learning disabilities die younger and more frequently from avoidable causes.
• Black, Asian and minority ethnic groups face disproportionately poorer health outcomes.
• Deaths from avoidable physical health conditions are more than twice as likely for people with learning disabilities.

These findings reinforce the urgent need to commission services that are not only safe and local, but also inclusive, equitable and culturally sensitive and responsive.

Progress Made, But the Target Remains Out of Reach

The message from data and watchdogs is clear: change is too slow, and lives are still at risk. While inpatient numbers for people with learning disabilities or autism have fallen by 29% since 2015, the system still falls short of the Transforming Care Programme’s goal of a 50% reduction by 2023/24. This shortfall highlights not only a missed milestone, but persistent challenges around commissioning, accountability, local capacity and national oversight.

Why Community-Based Support Matters

When the right support is in place, hospital stays should be brief and close to home. However, to achieve this, we need to move away from outdated, institutional models and invest in tailored, community-based solutions. When support is local, flexible and built around the individual, it doesn’t just reduce admissions; it empowers people to live fuller, more independent lives, connected to their communities and in control of their futures.

As Building the Right Support emphasises:

“Just like the rest of the population, people with a learning disability or autism must and will still be able to access inpatient hospital support if they need it. What we expect, however, is that the need for these services will reduce significantly.”

The Role of Commissioners: Moving from Policy to Practice

Commissioners across the NHS and local government are crucial to turning policy into meaningful change. This means moving beyond box-ticking and investing in person-centred, community-based care that reduces inpatient admissions and delivers lasting improvements in people’s lives.

This means commissioning services that:

• Begin with the person, not their diagnosis.
• Provide inclusive, local housing and wraparound care.
• Evolve as individuals grow in confidence and capability.
• Uphold dignity, choice and human rights at every stage.

What Makes Commissioning Truly Effective?

Transformational commissioning doesn’t start with a contract. It starts with understanding people and building the right partnerships. It requires:

• Local Insight
  A deep understanding of the local population, informed by Joint Strategic Needs Assessments (JSNAs) and Health and Wellbeing Boards.
• Values-Driven Practice
  A commitment to dignity, choice and safety, aligned with CQC standards and the national Building the Right Support model.
• Collaborative Partnership
  Co-produced services that actively involve families, professionals and care providers – embedding prevention, inclusion and continuous improvement.
• Mainstream Flexibility
  Empowering mainstream services to adapt – rather than defaulting to inpatient care – particularly for those with complex behaviours or mental health needs.
• Building Local Capacity:
  Investing in community-based services and smaller, bespoke providers through innovative commissioning and strategic housing partnerships.

Transforming Care, One Life at a Time

While many systems are still catching up, some healthcare providers are already delivering on the promise of Transforming Care. At Gray Healthcare, we are proud to be one of them.

Our approach supports individuals with complex needs to transition from inpatient units into bespoke, community-based settings where they can rebuild their lives. With clinical oversight, adaptable person-centred care plans, and a focus on long-term sustainability, individuals receive the consistent, tailored support they need to build independence, maintain stability and thrive in their own homes.

Our model includes:

• Clinically informed, person-centred care planning.
• Flexible packages that evolve as independence grows.
• Integrated multi-disciplinary teams offering wraparound support.
• A commitment to reducing risk by increasing autonomy, not restriction.

Meaningful Outcomes Through Community-First Care

Our 2024/25 Outcomes Report demonstrates the tangible impact of our clinically informed, community-first approach:

• 35% average reduction in total support hours, reflecting greater independence and improved skill development.
• 68% reduction in physical interventions, thanks to our trauma-informed, proactive approach using PROACT-SCIPr-UK®.
• 100% of individuals supported for more than two years remain in their own homes.
• Zero use of physical intervention in the form of seated, prone or supine restraint, in these long-term placements.
• 81% of individuals improved in functional skills.
• Few hospital readmissions.

These outcomes are more than encouraging statistics. They demonstrate real value for commissioners and align with national priorities to reduce inpatient admissions, promote independence and improve long-term wellbeing.

Meet Femi

Femi experienced significant trauma from a young age, which led to long-term mental health challenges and multiple years spent in secure inpatient hospitals, far from home. By the time we met him at age 23, Femi had been sectioned under the Mental Health Act 1983 (2007) and carried several complex diagnoses. Understandably, trust for him was difficult, and his daily living skills were limited. But Femi had one clear goal: to live a life like anyone else – independently, safely and with dignity. With that in mind, we co-designed a bespoke 24/7 care package built around trauma-informed support, emotional safety and gradual skill-building. Take a look at the care package we designed for Femi →.

From Policy to Practice

Transforming care is about more than policy. It’s about creating lasting, meaningful change for people with learning disabilities, autism, mental health conditions and complex needs. That means commissioning with purpose: prioritising community-based support, personal dignity and long-term sustainability.

With the right partners, tools, and commitment, we can ensure fewer people are admitted to a mental health hospital unnecessarily, and more people are supported to live fulfilling lives in their communities.

Bespoke Support, Brighter Futures

At Gray Healthcare, we work closely with commissioners, NHS teams, local authorities and families to create bespoke support packages that promote independence and reduce reliance on hospital care.

Our experience shows that when the right foundations are laid from the outset, adults with complex needs can thrive in supported living environments. With careful planning and the right team in place, we can offer individuals not just a placement, but a sustainable, less restrictive life in a home they can truly call their own.

Contact Us Today

Reach out to us today to learn more about our bespoke supported living services, and explore whether our clinically informed, community-first model could be the right option for the people you support.