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The raw deal that people with learning difficulties often receive could be about to improve. Peter Kinsey and Sarah Maguire look at the recommendations of the new white paper and add a few suggestions their own.

Most people with learning difficulties who receive services have a poor quality of life. Compared with non-learning disabled people, they are less healthy, have more limited social relationships and live lives that are more routine and less stimulating.

Why? The answer is complex and many factors are involved. One reason may be that supporting people with learning difficulties to lead a meaningful life requires skilled staff, yet service providers frequently employ staff with limited skills, on low pay and with only basic training. Another likely factor is a social care market in which service users sometimes appear as commodities to be traded, and where there are clear divisions between commissioners and providers.

However, there are services that achieve outstanding outcomes for people with learning difficulties, often with the same or fewer resources than other, poorly performing, services. Most people with learning difficulties can have good quality lives, but to achieve this a framework of rewards and penalties needs to be in place. That framework should apply not only to commissioners and providers of learning difficulty services, but also to other key players who can have a big impact on people's lives.

This is a positive time for people with learning difficulties with the newly published White Paper Valuing People¹ and more interest and attention from central government than at any time in the past 30 years.

We need to look at how rewards and penalties can be used to lever better services for users in three crucial areas: power and control, partnerships and the workforce.

One of the key reasons why services remain poor for so many people with learning difficulties is that traditionally they have little power and control over their lives. Among the critical issues that endow people with power and control are money, status, legal rights, and the opportunity to influence and shape opinion.

In the context of learning difficulty services, the white paper envisages the development of direct payments that will give people the power associated with holding the purse-strings. But we would also like to see people with learning difficulties gaining a legally binding care plan, developed using person-centred planning, which both commissioners and providers would be required to implement. Service users would be entitled to legal redress if key elements of their care plan were not forthcoming. This system, combined with a legal right to advocacy, would give service users and their families real and meaningful power in their dealings with services.

We are aware of the impact of the media and of publicity, positive and negative. We need, as part of the new white paper, a system that publicises the performance of learning difficulty services in a way that is accessible for users and carers. What is needed is not a meaningless set of league tables, but a performance framework that directly measures outcomes for service users. Those outcomes could include the number of people in some form of employment; those with their own tenancy agreement; and those who have a person-centred plan.

The London strategic framework proposes that service users and carers should prepare an annual report on the performance of local services. This should be allied with the publication of information about local services, to enable people with an interest to hold commissioners, and others, to account for their performance.

With regard to partnerships, learning difficulty services need to work with a range of other individuals and organisations to achieve good outcomes for service users. Those organisations include housing departments, education departments, leisure services and the criminal justice system. Inevitably, learning difficulty services will always be marginal to the activities of large public authorities. We need to find a way of including learning difficulty issues on the agenda for those services which will create clear accountability on the part of senior managers to deliver improvements to users.

We would also like to see a joined-up approach to performance assessment so that, for example, there are clear standards and targets relating to learning difficulties against which directors of social services are measured as part of joint reviews. This is hinted at in the white paper. Monitoring of housing associations by the Housing Corporation could also include clear measures of the range of accommodation offered to people with learning difficulties. The performance assessment framework returns that social services departments are required to send to the Department of Health could also include clear markers in relation to learning difficulty services, along the lines of the performance indicators outlined earlier. The Best Value system could also be exploited to achieve better outcomes for service users across a range of local authority services. We recognise that for people with responsibility for a range of service user groups, this is a way to keep services for people with learning difficulties at, or near the top of, the agenda.

But it is the workers who have to deliver frontline services. Rewards and penalties could be implemented in a way that achieves much better staff performance, while avoiding the mechanistic approach associated with systems such as performance-related pay. Although learning difficulty services have a strong history of developing and articulating values, they tend to be far weaker at turning those values into measurable roles for staff. A code of conduct would clarify the roles of frontline staff and explicitly state behaviour that is expected from people working in learning difficulty services.

The new learning disability award scheme, highlighted in the white paper, could be used to tailor accredited training programmes that would equip staff to understand and adopt the expected behaviours, which in turn achieve good outcomes for service users. This approach could be developed to provide an effective method for measuring staff performance, which could be built into regular supervision and appraisal.

The commitment and skills of frontline staff in learning difficulty services are often overlooked. Service commissioners should take an active role in promoting and celebrating good practice in local services. Rather than the divisions that exist as a result of the social care market, commissioners should take the lead in bringing together frontline staff and managers from across provider agencies to share innovative ways of working.

A culture must be created where staff are encouraged to celebrate success and to take pride in the good outcomes they achieve with service users.

¹ Department of Health, Valuing People: A New Strategy for Learning Disability in the 21st Century, The Stationery Office, 2001

Peter Kinsey is locality manager, Surrey Oaklands NHS Trust, while Sarah Maguire is director of Operations, Choice Support.

White paper spans the stages of life and agencies

The English learning difficulties White Paper Valuing People attempts to cover every aspect of life for people with learning difficulties, from childhood to old age, using a cross-government approach, writes Linda Ward.

The paper covers agencies involved in contributing to better lives for people with learning difficulties - housing, leisure, education, health, and so on.

- The largest section, "Better life chances for people with learning difficulties", covers disabled children and young people; choice and control for people with learning difficulties - including advocacy, direct payments and person-centred planning; supporting carers; improving health for people with learning difficulties; housing; fulfilling lives and employment; and quality services - including workforce training and planning issues, and the learning difficulties awards framework.

- Another section, "Delivering change", covers national and local action. National action includes the establishment of a national learning difficulties task force, a learning difficulties development fund, and an implementation support team and fund. Local action includes the establishment of learning difficulties partnership boards and joint investment plans.

- There is a five-year implementation programme encompassing detailed targets and deadlines from spring 2001 until March 2004, as well as objectives and sub-objectives, targets and performance indicators.

Linda Ward is a professor at the Norah Fry Research Centre, Bristol.