Commissioners are ‘complacent’ about meeting the government’s ambition of ending inappropriate hospital placements for people with learning disabilities or autism and ‘challenging behaviour’ following Winterbourne View.
That was the message from the head of the government-funded programme launched in December 2012 to help councils and NHS commissioners radically reduce the hospital population – numbering approximately 3,200 – by investing in community provision.
Bill Mumford, director of the Winterbourne View Joint Improvement Programme (WVJIP), said the government’s original ambition of ending inappropriate placements by June 2014 would now not be met.
He said that “there is no doubt that where we are is nothing like where we wanted to be” and that the WVJIP was having to be “re-engineered” so that the support was “more focused” on helping commissioners deliver the necessary changes.
Mumford was was seconded to lead the WVJIP in December from his role as chief executive of learning disability provider Macintyre, following the departure of its previous two leads, Chris Bull and Ian Winter and amid criticism of how the programme had been run in its first year.
Mumford said he was now looking to the end of the joint Local Government Association and NHS England-run programme in the summer of 2015 to bring the hospital population down to a “therapeutic minimum”.
But he said that he wanted to use the June 2014 target to drive greater progress than is currently being made in reshaping services.
“We are going to use the June target to put as much pressure on the system as possible because there is complacency. Numbers are high and they need to come down and keep coming down,” he said. “By June I want to see numbers coming down.”
The programme is a personal priority of care minister Norman Lamb, who has threatened to “name and shame” commissioners failing to take adequate action. Mumford said commissioners still felt “challenged” by the programme and wanted to “do better” and that the programme wanted to harness this goodwill.
However, he said that good practice in some areas were not being followed in many others. For example, in Sunderland, commissioners tracked the placements of people with learning disabilities or autism and ‘challenging behaviour’ to identify key issues such as readmissions to hospitals or delays in discharge. This information was then shared in anonymised form with stakeholders, including families of people with learning disabilities, so they could challenge commissioners on progress.
Mumford said this approach needed to happen everywhere, and the WVJIP would be aiming to work “area by area” with commissioners to spread good practice, and promote “peer to peer learning” in which commissioners learned from each other.
NHS England will also be collecting data on a quarterly basis from NHS commissioners so that people could be tracked through the system.
“I think that this is really important to the success of this programme.” “It will enable us to highlight individual situations and ask commissioners ‘what are you doing about Johnny or Mary?’.”It will show whether people have moved from one hospital placement to another, or from one level of security to the next or whether they have been discharged and then readmitted.”
The programme, which has received £2.86m from the Department of Health, has two improvement advisers – Zandrea Stewart and Stephen Taylor – available to support commissioners, which Mumford admitted was a “tiny resource”.
Sixteen areas are currently receiving in-depth support from the programme, with a further 19 due to be added by the end of April. Other areas will receive some support dependent on their self-assessed needs, which could involve one-to-one support from Stewart or Taylor and a pool of experts whom they draw on, attending local or national events or support from regionally co-ordinated partnerships.
Mumford said the programme was looking to tackle some of the key blockages to reform that were identified in a stocktake of progress based on self-assessments by local commissioners last year. These included a failure on the part of councils and clinical commissioning groups (CCGs) to pool budgets and share the risks of transforming care, and the fact that the commissioning of placements was split between CCGs and NHS England specialised commissioners.
“Over the past two weeks we’ve hosted a couple of events with specialised commissioners and local health and social care commissioners. We’ve said to them ‘everybody says there are communication issues, let’s put everyone in a room together’.That’s been really useful in understanding the issues.”
Mumford said the challenges of providing appropriate community support for the people concerned was underestimated at the time the programme was launched, alongside a concordat to transform care signed by 51 leading sector organisations.
The original focus had been on people with learning disabilities or autism admitted to assessment and treatment units following a crisis in their community support or because of pressures on their families.
“But there’s a more complex population when you move into the low and medium-secure units, who have higher risk profiles,” said Mumford. “Within that group there are the people who come through the courts system and those who are there through clinical judgement. Understanding this group is difficult.”
While some of this group would be on court orders that prevented their discharge from secure hospitals, others could be supported into community settings, he said.
As part of the WVJIP, an Improving Lives team has been set up by NHS England to review the cases of the former residents of Winterbourne View and other people with particularly complex needs or in situations of concern.
He said this was “providing us with a more detailed analysis of some of the most complex situations” and identifying how “people seen by clinicians as too high-risk for community-based services” had been supported to leave hospital.
Mumford also admitted that the programme was working in a particularly challenging context in the light of the wholesale changes made to the NHS in April 2013 and the significant cuts in government funding to councils made since April 2011.
However, he added: “A lot of what I’m talking about is behaviour change. Local areas working together with less resource will always do better than areas who are not working together with more resource.”
Mumford’s comments come with the quality of care in assessment and treatment units under increased scrutiny following the preventable death of 18-year-old Connor Sparrowhawk in a unit at the Slade House service run by Southern Health NHS Foundation Trust.
As a small service providing short-term placements to local people, the unit Connor was placed in represents the form of hospital care that the government intends to become the norm for people with learning disabilities who need inpatient care in future.
However, both the Care Quality Commission and the independent investigation into Connor’s death found significant failings of management and care at the unit, which is currently closed to patients.