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10 Dec 2012
Bill Mumford, chairman VODG, managing director, MacIntyre

Making the Concordat Concrete

Just over a year ago, MacIntyre shared the inspiring story of Joe in the VODG report Another Way, proving how collaboration between commissioners and providers can avoid the trap of long stays in out-of-county assessment and treatment centres.

Bill MumfordJoe was in an assessment unit for six months where he was often restrained by a four-strong staff team up to 15 times a day. But his council’s creative-thinking commissioners engaged MacIntyre and with the support of their No Limits flexible, bespoke programme, Joe successfully moved into supported housing near his family. This is just one of many examples of how VODG members have developed good local alternatives to the institutional model of assessment and treatment hospitals.

The Department of Health (DH) has today published its final report into the failings at Winterbourne View alongside a concordat on learning disability, the national public commitment to deliver the right care for individuals (see box,The main commitments in the concordat). It commits the signatories like the VODG to “a programme for change to transform health and care services and improve the quality of the care offered to children, young people and adults with learning disabilities or autism who have mental health conditions or behaviour that challenges to ensure better care outcomes”.

As the minister said at a roundtable event that I attended today with other sector contacts and family members: "People can't hide from or avoid the necessity for change"; he also called for national leadership "to go with local action".

The VODG welcomes the strong statements from the government that hospitals are not homes; people should not live in hospitals which are often located a long way from the family home and for extensive periods of time. Good alternatives do exist but they need to be universal and each Health and Wellbeing Board should ensure good and comprehensive arrangements are made in their area.

The concordat is not perfect - it’s taken 18 months to get this far, but it does have the potential to bring about real and lasting change after the scandal of Winterbourne View. The commitments in the concordat need strong and sustained leadership from the DH over the next three years to put everything into action and I am pleased that the care minister, Norman Lamb, is personally chairing the programme board which will oversee delivery. The action plan is commendable – but the challenge is how to ensure that everyone engages in it. Good practice is being evidenced by the best commissioners and providers– but what about the rest?

The main commitments in the concordat are:

  • Health and care commissioners will review all current hospital placements and support everyone inappropriately placed in hospital to move to community-based support as quickly as possible and no later than 1 June 2014:
  • Every area will put in place a locally agreed joint plan for high quality care and support services for people of all ages with challenging behaviour, that accords with the model of good care
  • There will be national leadership and support for local change
  • Planning will start from childhood
  • Regulation and inspection of providers will be tightened (eg CQC will use existing powers to seek assurance providers have regard to national guidance)
  • Progress in transforming care and redesigning services will be monitored and reported (eg DH will publish a follow-up report one year to ensure the steps in the concordat)

Despite the theory about health and social care working together, this is still something of a holy grail. How well CCGs and the NHS works with other stakeholders to try and deliver change – together with local authorities and the third and private sector – is a thorny issue. Many of the current assessment and treatment hospitals are actually run by the NHS and they need to reach out to other partners when seeking to create new models of support. I fear there remains a misconception among some health professionals that community-based social care providers do not engage with individuals with as extreme needs as health providers do. They remain skeptical about joint working and some find it hard to conceive of a service that isn’t about buildings and beds. Success is: fully integrated local partnerships.

Part of the new landscape for the VODG is how we collectively as providers collaborate with local authorities and health around community-based social care. The bottom line is that we know alternatives – another way, as our report showed last year - to Winterbourne exists, the problem is replicating alternatives on a grand scale.

Creative and strategic commissioning is central to making change happen and to ensuring that the next generation of people with behaviour that challenges enjoy better environments and support.

As well as bringing home individuals who are stranded in poor quality and ineffective care miles away from home, we need to ensure no more new people move into such services. The concordat must lead us to an almost complete closure of remote assessment and treatment units, the prevention of such units “re-branding” but essentially perpetuating the wrong model of care and the nationwide creation of a comprehensive range of flexible, locally available and person centred support arrangements. Arrangements that will that render the likes of Winterbourne unnecessary - forever.

The VODG should like to see more emphasis on continuity between children and adult services so the individual and family have a fully supported and seamless pathway Additionally, as I’ve blogged here before, that NICE could play a much more significant role than that currently expressed, by being required to carry-out a thorough evaluation of assessment and treatment centres in terms of their clinical effectiveness and value for money in comparison to local alternatives.

Furthermore we welcome the government’s commitment to support the Winterbourne families through advocacy; we see advocacy as another important piece of the jigsaw if today’s commitments are to turn into real action for all. Each person in an assessment and treatment hospital has been promised a new person centred assessment but will those undertaking that assessment know of what alternatives look like. If not there is a fear is that some of the poor quality services today’s concordat seeks to eradicate will simply be re-created in a similar likeness and operate in essentially the same way.

We believe that funded professional advocacy support (where appropriate) for all those people currently placed in assessment and treatment centres should be funded and made available without delay. The cost of this – given the numbers of people involved – would be minimal compared to the costs of such placements and such support has the potential to significantly improve individual lives. Our recent report, Advocacy: a voice for our future, demonstrates the crucial role effective advocacy can have in a person’s life.

We wholeheartedly welcome the sentiments in today’s concordat, the VODG members will enthusiastically do our bit but several notes of caution need attention if its laudable commitments are to become concrete.