By June 2014, no one with learning disabilities or autism and “challenging behaviour” should be receiving support in a hospital setting, other than for short-term periods of treatment, in small units close to home. That was the central message from the final report of the government’s review into Winterbourne View.
Large assessment and treatment units like Winterbourne should be consigned to history, with people supported to live in community-based settings, such as supported living or Shared Lives, including through the availability of good-quality local mental health services that can respond to crises.
While many social workers, providers, advocates and families will have a key part to play in achieving this ambitious goal – there are currently an estimated 3,400 people in inpatient NHS-funded learning disability beds – it is chiefly a commissioning challenge, for councils and the new clinical commissioning groups (CCGs) in the NHS.
They will need to ensure there are social care, health and housing support services in every area to provide the 15,000 people with learning disabilities or autism and behaviour perceived as challenging with the support they need to remain within their communities.
To support commissioners, the government has provided the Local Government Association and NHS Commissioning Board with almost £5m to fund a programme of support from now until March 2015; appointed to lead it is former senior sector manager Chris Bull.
Bull, who is now working in interim roles, has amassed more experience than almost anyone managing across the NHS-local government divide: from 2007-12 he was, jointly, chief executive of Herefordshire Council and Herefordshire Primary Care Trust, and previously spent five years holding the joint post of director of social services at Southwark council and PCT chief executive.
Joint working experience
This experience of joint working should prove invaluable for a programme that will be built on NHS-local government co-operation. The government’s agenda implies the replacement of NHS spending, on long-term hospital placements, by council spending, on supported living and social care; to avoid too great a burden on councils, this will require “pooled budgets with shared accountabilities”, say ministers.
Despite the risk of funding tensions between councils and NHS commissioners, let alone the fact that the identity of those NHS commissioners will change on 1 April, from PCTs to CCGs, Bull is optimistic.
“There’s an incredible commitment to change [across the country],” he says. “I’ve got no doubt that people will give it priority.” This applies to the emerging CCGs, though he says he would like them to each appoint an officer to take leadership of the Winterbourne agenda.
Bull says his programme’s role will be to help commissioners to develop new models of care so that the “investment going into assessment and treatment services can shift into more appropriate community settings”.
Shifting investment out of hospitals
This is no easy task at a time of declining budgets for councils and static funding for the NHS; pulling resources out of hospital settings to fund community alternatives may damage the viability and quality of the former before the latter are fully developed.
Bull acknowledges this risk, and says the programme will seek to fill gaps in capacity locally. “There may be concerns in the system about capacity but it’s part of our job to use some of the funding made available to us to help people develop commissioning plans,” he says. “I want to spend the vast majority of the money I’ve got on supporting commissioners.”
He will be supported by a small team, which will include people with project management skills and “real expertise in the [learning disabilities] field”, whether in commissioning, provision or academia. Bull says they will be chiefly deployed working with those commissioners who need greatest support, though he adds that “a degree of change is required everywhere”.
Getting providers on board will also be another key commissioning challenge that the programme aims to help with.
Provider role key
“We can’t simply assume that commissioners will say they want and providers will then provide what commissioners want,” he says. “What we need to do is work with providers who currently provide services and those who intend to provide them and have a debate with them about how they can move from the current type of provision to the new type of provision.”
While large learning disability providers with diverse portfolios may have little to fear, this poses a significant challenge for providers with a significant focus on hospital care and little or no supported living provision.
“Obviously we will be talking to [these providers],” he says. “That’s one of the issues we will need to work through.”
However, the main arbiters of success, he says, will be service users and their families.
“The key thing is that people are placed in services that are generally appropriate for them and that meets their needs and which they and their carers have confidence in,” he says. “The core assumption is that these services are community-based.”
Winterbourne View ‘a case study in institutional neglect’