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29 Jun 2012
John Adams, VODG general secretary

DH déjà vu? Why the latest Winterbourne report must take firm action

A depressing sense of déjà vu hangs over the Department of Health’s (DH) recent interim report, part of its review into the Winterbourne View scandal. Some people with learning disabilities, it concludes, are being failed by the health and social care system.

John AdamsIf this sounds familiar, it’s not just because the report is based on the CQC’s latest inspections into 145 homes that concluded half the settings inspected failed to meet the health and social care watchdog’s standards. It’s because the DH conclusions echo those of the late Professor Jim Mansell’s reports (1993’s Mansell Report, revised in 2007, and 2010’s Raising Our Sights). It shows little has changed since Ivan Lewis, then under secretary of state for care services wrote in the foreword to the 2007 Mansell Report’s that “commissioning and providing services for people who present significant challenges is one of the major issues facing learning disability services.”

We all – the public, policy makers and care providers - hope that the widespread national anger and shock at the abuse filmed by BBC’s Panorama’s at Winterbourne indicate that the system might Winterbourne Viewfinally change and make it easier to rid the sector of such poor quality care.

But the themes running through the latest reports are, in essence, the same that appear in its predecessors. Furthermore, the gulf between the latest recommendations – from more access for families to a concordat on care - and the reality facing families, commissioners and frontline staff is too wide. Will any actions set out by government finally create the necessary change, drive up quality, protect people with learning disabilities and raise standards?

Yes, but only if - and remember the DH’s report is an interim one - the government outlines some more concrete actions.

One potentially powerful move would be steps to alter local commissioning practice and directly or indirectly restrict outdated service models of institutional care. The government could simply require the phasing out of existing units like Winterbourne and prevent new ones from entering the market. It could work with commissioners, families, individuals with a learning disability and providers to co-design more dignified and suitable types of support.

If the government really wants to encourage wholescale change, the DH could be more forthright in leading on quality. For example, ever since the misconceived consultation on the so-called replacement for star ratings, an issue we have campaigned on, there has been a deafening silence. Likewise the suggestion that the DH will work with providers to develop a voluntary quality accreditation scheme – this is welcome, but for people who had the misfortune to be at Winterbourne and other homes like it, is too little, too late.

And, seeing as models of care still seem left to market forces, the CQC could rethink its largely neutral stance as a watchdog. Instead of its statutory remit to check whether services are legally registered and compliant, the CQC could play a more strategic and pro-active market shaping role and could, with the government’s support, ensure that no further institutional style services (for people with all sorts of needs, not just learning disabilities) are allowed to enter the care market.

Influencing commissioning and service design requires more collaboration and partnership working between people who use services, their families and advocates, commissioners, CQC and providers. The DH report, for example, says that many commissioners are unaware of good practice in commissioning for people with learning disabilities, autism or behavior that challenges. This, a well-documented issue, means commissioners need not only a massive change in culture but also urgent training and, in some cases, replacement. The latter must surely be the only option when, as the CQC report illustrates, some people have been left stranded for years in treatment and assessment centres.

As Rob Greig of the National Development Team for Inclusion (NDTI) has pointed out, the levers for local behaviour change are not explicit. Yes we’ve had many strategic discussions and good intent across an awful lot of organisations, but no one holds ultimate responsibility.

A similar model to the successful neurological commissioning support service, where commissioners can benefit from the experience of people who use neurology services, needs to be developed for learning disabilities. This could be one way of securing the care and support service users and carers need.

Transforming and improving care demands more emphasis on social care leading the response working alongside the NHS. In particular ADASS (Association of Directors of Adult Social Services) need to spell out how it will support commissioners locally to change their behaviours.

And, for the most vulnerable, what about a named worker responsible for tracking an individual and – here’s the crucial part - sticking with them? Someone who could speak up and influence on an individual’s behalf (note that advocacy is only mentioned in the DH interim report’s national actions in terms of the government promoting “open access for families and visitors including advocates”). Imagine the impact on an individual’s experience of care if they could count on someone to cut across boundaries to project manage and ensure a good local solution is put in place.

In a joint statement commenting on the DH’s interim report, Mencap chief executive Mark Goldring and Challenging Behaviour Foundation chief executive Viv Cooper: “Action is needed to stop people with a learning disability and behaviour that challenges being sent away to these services [large, out-of-town units]. The government’s proposals on local action will not be enough to create the systemic change needed. We are looking for a direct commitment from government to put in place a strong, practical action plan with clear targets when it publishes its final review”.

Watch this space, as Goldring and Cooper have said and hopefully the government will fill it with clear, powerful obligations for providers and commissioners to spark transformative change in partnership with families and regulators. Only firm directives and plans that change commissioning practice will eradicate the likes of Winterbourne from our sector, rather than well-intentioned, well-thought out words that, while welcome, fail to make a lasting difference.

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