Cultivating quality

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.