Why are the numbers in assessment and treatment units increasing despite the efforts of the Winterbourne Joint Improvement Programme? Chris Hatton has a theory and some radical suggestions for reversing this trend.
Over three years on from the original Panorama exposé and with less than one year left of the official Winterbourne Joint Improvement Programme, the latest information from NHS England(1) is that the position is not only not improving as quickly as was planned but that things are actually moving in the opposite direction to that mandated by the programme.
In this blogpost I want to confine myself to a few observations and a proposal that suggests a very different starting point to the current approach.
Observations
1. There is a discrepancy in the numbers, between the 3,250 people in these services identified in the latest learning disability census (2) and the 2,615 people in these services identified in the latest returns from commissioners. The reason for this is quite straightforward – both numbers are correct, it’s just that there are around 500 people in these services health commissioners don’t know about. If a person has been in one of these places for a long time (which we know isn’t unusual) how many reorganisations of commissioning have taken place (let alone all the internal reorganisations and relabellings) in that time. Are the cheques still being paid while the person has quite literally been forgotten about?
2. For the first two quarters for which data have been available, the number of people being transferred into these services has been substantially bigger than the number being transferred out. I was shocked by this at the time but on reflection I should not have been surprised. The focus of the Winterbourne programme has largely been on people already in these services – understandable but unlikely to be enough to tackle the systemic combined behemoth of fragmented commissioner inattention and provider expansionism supporting these services (3).
3. I can understand the dilemma of whether to set up the Winterbourne programme on a time-limited basis. However, the limited amount of time left presents a real problem. From what we’ve seen so far, I suspect that many commissioners and providers will be tempted to stick it out and hope that any pressure being exerted by the Winterbourne programme will go away.
4. According to the latest NHS England figures, by far the most common reason given by providers (via commissioners) for people not having plans to transfer out is a ‘clinical decision’.
This for me raises questions about the appropriate status and role of psychiatry in these services:
• Although these are designated ‘hospitals’, institutions for people with learning disabilities were originally run by local authorities and it was only the creation of the NHS in 1948 that magically turned these places overnight into health services, partly through their gradual colonisation by psychiatry throughout the 19th and early 20th centuries.
• Reasons for transferring people into ’hospitals’ are frequently reported as ‘learning disability’, ‘challenging behaviour’ or ‘mental health problem’. The first two are not in themselves health issues and effective support for the third can frequently come from non-medical approaches.
• One would hope that ‘hospitals’ would at least provide effective physical health care for people with learning disabilities (especially as they can underpin many behaviours labelled as ‘challenging’ (4) ), but #justiceforLB and many other people’s experiences show that this simply cannot be guaranteed in these services.
• There is precious little evidence that these services as a ‘model’ of care are routinely providing high quality therapeutic environments for people on the short-term basis they are apparently set up to provide. With over two-thirds getting anti-psychotic medication in the last month, over a third experiencing hands-on restraint in the last three months, 60 per cent having lived in the service for a year or more (all from the learning disability census), these services are not delivering on their own terms, let alone according to other ways of thinking about a person’s life.
An action plan
I offer this plan as a sketch of what could happen if we start from a different set of assumptions and as the start of a conversation.
Most commissioners got nowhere near the target for transfers out by 1 June 2014 and, I suspect, may be too small, fragmented and focused elsewhere to give the matter proper attention.
– All these services should be closed to new admissions, CQC to make a clear statement that they will not register new services of this type and that they will have a process of de-registration of existing services.
– Funding should be withdrawn from all commissioners still funding people in these services, that funding to be administered by a national closure taskforce. This would give the taskforce a starting budget of over half a billion pounds per year – and the Winterbourne View programme money could be added to this.
– Put people with learning disabilities and families really in charge of this taskforce, making decisions about who is appointed to work on the taskforce, in which capacities, and what it does.
– The taskforce would work to develop local, individual supports for people moving out of these services – with new people, agencies and supporters rather than the usual provider suspects (unless the usual provider can come up with something the person and family members want). This would be person-centred, with the person and family in charge of circles of support.
– Funding, provided at the same level as the assessment and treatment centre, to move with the person (I hear howls of protest and accusations of a two-tier Rolls Royce service but it would demonstrate what good looks like).
– The taskforce would also help to develop local, individual supports for other people with learning disabilities who might have been sent to these places by commissioners, including strong local structures for self advocacy and family advocacy.
– The taskforce would help to develop ways of supporting people with learning disabilities in acute distress/crisis for short periods.
Web links
ourwork/qual-clin-lead/wint-view-impr-prog/
3. chrishatton.blogspot.co.uk/2014/04/
acts-of-commission-commissioners-and.html
4. www.improvinghealthandlives.org.uk/
securefiles/140602_1606//Factsheet-CBed.pdf )
Chris Hatton is a researcher at Improving Health and Lives: Public Health England Learning Disabilities Observatory.
We are grateful to Chris for giving us permission to re-produce this blogpost.
