Read full transcript of interview with learning disability director Rob Greig

Interview with Rob Greig, who is the government’s
learning disability director of implementation.

The interview was done with Community Care’s
chief reporter Lauren Revans before Christmas.

How is your first month going?

The first month has been about getting to grips with the
organisational side of things. We’ve been appointing the team
of regional workers, and they’re all coming into post in
January (2002). I’ve been particularly getting involved with
supporting quite a bit of the good practice guidance. But also, for
me, just getting to understand the department of health.

How does working in the government compare with working in
the university sector?

And before that I was in the NHS. I suppose I’m finding
out is the answer. Clearly there are different ways of doing
things. But for me one of the great challenges is that I am used to
being able to say very freely what I think and what I feel.
Obviously I have to ensure that whilst I’m not in any sense
compromising my beliefs and my principles I obviously have to think
of the wider context to my workload than to how I perhaps did
before.

My role and that of the team is not that of traditional and
conventional civil servant and department of health people. We are
very clearly working at the interface between the department and
people on the front line. And therefore our way of operating will
need to reflect that. We will need to learn to respond to the needs
and demands in the field and political expectations within
government and marry those both in our style of working and also
the things that we do.

I’ve spoken to some people in the learning difficulties
sector and tried to gauge their views on how they think things are
going and what they are still concerned about. And surprise,
surprise their top priority is funding. Their number one fear and
concern is money. Is there going to be enough money? I understand
there’s £42m for the first year.

Yes – £22m of revenue and £20m of capital.

Is that really going to be enough?

I think people really need to understand what the money is for.
The money is not intended or envisaged to fund new services. The
revenue element is not – the capital element obviously is to
contribute towards new service development – but the revenue
is not intended for new services. It’s intended to oil the
wheels of change and to help.

The big thing about Valuing People I think is not about the
service change that it talks about but the change in organisational
and cultural behaviour that’s essential if people’s
lives are going to improve. The development fund is targeted at the
kind of things that will help achieve those changes.

For example?

For example, supporting the development of advocacy, helping
implement person-centred planning, helping people get to grips with
partnership work. Because if we just change the services, like if
we just change the day centres into something smaller and different
but we don’t change the ways in which people in organisations
behave towards each other and particularly towards people with
learning disabilities, then these new services in two or three
years time would feel, to the person with a learning disability,
just like the old services.

So what we’ve got to do is change the way in which people
in organisations behave. And that way, the services will begin to
change – it will naturally happen. If you’re listening
to people with learning disabilities, if you work in partnership
with other organisations, and if you’re being evidence-based,
then you will naturally begin to develop and change the day
centres. There’s no other way of doing it. Rather than
starting with the centres and changing the services, my argument is
start with the management and organisational culture. Because that
way I think we will get more sustainable change over a period of
time rather than superficial change that won’t last very
long.

So that’s about that bit of money. But I think there are
three or four things I was going to say about money. That’s
the first one – about money to oil the wheels of change. The
second thing is there is over £3 billion spent on health and
social care every year at the moment. For the last eight or nine
years I’ve been working as a development advisor across the
country. I’ve worked in nearly two-thirds of authorities
across the country. And I’ve never worked anywhere where that
cannot achieve better lives for people with learning disabilities
with the money they’ve got at the moment by doing things
differently. That’s the starting point to that question. And
that’s not to say there isn’t a case for more money.
But when we did all the consultation for the white paper, the
biggest message coming from people with learning disabilities was
that the biggest change people could make was to treat them
differently, ‘to value us and respect us in the way they
behave towards us’. Now that doesn’t cost a huge amount
of money. So my second point on money is that we can do a lot
better with the money we’ve got.

My third point is that there is a lot of money outside the
learning disability sector that we are not accessing. Education,
housing, employment. About 12 years ago I was involved in setting
up one of the very first supported employment agencies and when I
met the people running that a few months ago they told me that they
are still getting the same amount of money from social services as
they did when I left there eight years ago but they are reporting
about five times the number of people into employment. And the
reason is because they have got money from the employment sector.
The employment sector has begun to realise that it is legitimate
use of employment money to get people with learning disabilities
into jobs, and that its not the job and shouldn’t just be
health and social care money that helps get people into jobs. The
same thing should apply with other areas. The thing that I would
add to that list as well is the National Service Frameworks. There
is significant money that is going into National Service
Frameworks, and some of that should be directed towards people with
mental health and learning disabilities.

The fourth point’s a really important one. It’s
about evidence. The learning disability field does not have a very
strong evidence base. I think that one of the things that we have
to do locally and nationally is that we need to get better at
getting the evidence about what is needed, what are the service
supports that will meet that need, and how they work. Because if we
can do that we can make our case for more money. One of our
problems at the moment is that when faced with NHS cuts,
demonstrable effective interventions for cancer and heart disease
compared to not very well argued and articulated learning
disabilities cases may mean we lose out. We’ve got to get
better at that. One of my key tasks I feel is to help people
develop the evidence base so we can make the case locally and
nationally in two, three, five years time.

There is no amount within the Standard Spending Assessment
ring-fenced for learning difficulties. Do you see a future role for
ear-marking or ring-fencing part of the money for learning
difficulties?

The problem with ring-fencing is that it’s just as easy to
kind of bow yourself out as bow yourself in. I’m not
convinced that ring-fencing necessarily helps. I think there is a
case for, as additional money becomes available, targeting it at
specific deliverables in the way that for example making a specific
grant did. That’s why I think the way the development fund is
working is saying you decide locally which is your priority amongst
these three or four issues but you have got to spend it on that and
demonstrate that the reason you are spending it on that is because
of either identified local need or priority. I think that’s
the way forward rather than trying to in some way ring-fence the
whole lot.

I guess what we must also remember is that, as local authorities
and health authorities get into partnership and pool budgets, then
in a sense that does publicly identify what the resource commitment
is to learning disabilities at a local level. And that is helpful
because that creates openness and makes it easier for people to
work together because there’s less concern that there’s
money being hidden away in the back pocket.

The White Paper is not going to be legislated on. But if
local authorities are strapped for cash and something has to go,
they are going to get rid of the services they don’t have to
provide by law first. What can you do to ensure that there are
enough sticks and carrots around to make sure they do deliver on
the White Paper?

Financially the development fund will grow over time, as the old
long-stay centres continue [to close]. That money will get recycled
back in, so that will be one way of helping ensure that. But I
think that the biggest way that we can achieve that is to find ways
of partnership boards – and local authorities as part of them
– becoming publicly accountable back to people with learning
disabilities and their families, so that if services are not being
delivered, if change is not happening, if what is being delivered
is not what people want and need then, for the first time ever in
most cases, the people taking those decisions are having to
publicly explain and justify that to people with learning
disabilities and their families. And that’s a darn site more
difficult than an internal management decision, which is how things
have tended to happen in the past. And that’s why I think the
whole advocacy development agenda and the role of people with
learning disabilities on partnership boards is so crucial to this
because it will begin to change the culture of decision making and
prioritisation.

What other guidance are you planning to produce? I’ve
heard requests for some on housing, some on modernising day
centres, some on how local authorities and the partnership boards
can access the other funds that we just talked about, and about the
operations of the partnership boards themselves?

What has already come out is the section 10 guidance and the
guidance on involving people with learning disabilities in
organisational decision-making, Deciding Together. The partnership
guidance and the person-centred planning guidance will both be out
around Christmas. Guidance on health action plans will be out early
in the New Year. It is my intention that we produce something on
housing because there’s an expectation boards produce a
housing strategy for people with learning disabilities and I think
we do need to give them some framework. I don’t think it will
be detailed guidance in the sense the partnership and PCP guidance
is. I think it’s more likely to be a framework like the JIP
work book which we have already produced. I don’t see that we
need to produce anything on day services and day centres because
there has been so much produced already. There’s enough
experience and written material on how to go about doing that that
we would just be reinventing the wheel. I’m particularly
referring to work done by Barbara MacIntosh, the Changing Days
project. About accessing other sources of funding, I think rather
than guidance – there must be a limit to the amount of paper
we produce, we mustn’t swamp people with too much paper
– I think those issues and topics my regional team around the
country know about these sort of things. They are there as a
resource.

You mentioned the JIPs just now and there are other action
plans that have to be produced by the end of January.

No they are the same things. The terminology got slightly
confused at one stage. We are expecting people to produce a local
action plan for implementing Valuing People. And the local action
plan is the JIP. They are one and the same things. And that’s
by the end of January.

And guidance has gone out on producing that?

Yes

What monitoring arrangements are in place to ensure that
these plans are effectively implemented?

The Social Services Inspectorate will be monitoring and
reviewing the plans between January and March so as to advise
people at the beginning of April about their access to the
development fund. Because if the JIP does not represent a robust
local action plan for implementing Valuing People then the
development fund will not be forthcoming. But, having said that,
the last thing I want to do is see money not going somewhere,
because the people who will suffer at the end of the day is the
people with learning disabilities. My approach is that if the SSI
advise that a JIP is not acceptable then my team, my regional
worker in that area, will get into a dialogue about what’s
going to happen over the next year and provide the support that we
can to them to make the changes and fill the gaps that are
necessary in order for it to be acceptable. So it will be a process
of negotiation – so the person providing the development
support can help the local partnership board meet the expectations
of the SSI monitoring process.

If I can take you back to the idea of sticks and carrots,
one suggestion has been for performance indicators relating to
learning disabilities. Obviously that has good and bad points. Do
you have any plans to introduce indicators?

There are some new performance indicators in the process of
development. They are being consulted about with people like the
Association of Directors of Social Services. Those are aiming to
focus more on the outcome issues in Valuing People than some of the
financial process stuff. So, for example, we are exploring
indicators about things like people having jobs, people having
direct payments.

I’m also very keen to encourage partnership boards to set
some of their own performance indicators. I’m working on the
assumption that we are all grown up and that we are all trying to
do the best that we can. So I’m keen that people locally
identify what are their priorities and then publicly commit
themselves to trying to achieve certain changes or improvements,
and either monitor themselves or maybe work with neighbouring
partnership boards and do some peer monitoring reviews so that they
can hold themselves publicly accountable in a voluntary way as well
as being held accountable in the government target-monitoring way
that will always be there but is not in my way the only bit of the
equation.

You said earlier that there are lots of examples of how we
could be spending money already in the system more wisely. So, if
we are getting rid of long-stay hospitals, why are we still
spending money building new centres? Why are we still obsessed with
bricks and mortar?

I think that’s a very valid question. I think any decision
to construct and build new bed-based NHS facilities is something
that needs very strong scrutiny and justification on the grounds
that this is really what people need. And that’s where the
whole person-centred planning concept comes into play. One of the
most important things in the White Paper is the expectation that
people currently living in NHS residential campuses have their
needs reviewed using person-centred planning approaches and that if
it is identified that NHS campuses are not meeting their needs and
aspirations, then that should change. And that’s
important.

Obviously, it’s a lot more resource and cost intensive
to have people with their own carers on a one-to-one basis. Is
there a danger that perhaps where you might have had five days in a
residential or day centre, for the same price you might only get
two-and-a-half or three days worth of one-to-one?

There is no real evidence that that is the case. There is
evidence that small-scale individualised solutions can be as cost
effective as large scale residences. The big day centres in many
ways are a good example of that because once you actually begin to
free up opportunities and genuinely get into what’s happening
in the community you begin to build into natural patterns of
support. For example, when I used to manage services, I remember
that the manager of one of the supported houses asked for
additional staff because they had identified that someone they
wanted to support wanted to go to an evening class and they wanted
more staff to go there. That was actually resolved by a very small
amount of investment – which we used to meet the baby-sitting
costs of the neighbour, who was interested in the same evening
class but wasn’t going because they couldn’t afford the
baby-sitter. That wasn’t costly to do that. The other example
I will give was of a man who had a big reputation. He was very
challenging. We got him a job. The job was only three hours a day,
two days a week. But it had such an impact on his self esteem and
it had such an impact on the attitude of the staff who felt so
positive about the fact they’d got this guy a job and nobody
thought we ever could that everything just changed in that service.
The guy’s challenges just dropped off dramatically, the staff
were happier and were doing things very well, and 18 months down
the route there were four fewer staff in that support staff, and
yet people there were having a much better life. So it’s
about how you break into the cycle of the belief system that the
only way to get good quality services is to have more conventional
staff in conventional jobs. There’s something about trying to
find new alternative and different ways of doing things and by
doing that levering different types of resources.

So we need to be more flexible?

I think that we need to have a culture of positive risk taking,
as in you don’t start with the perspective that you say
it’s a reason why we shouldn’t do this. Your starting
point is you should always try something unless there’s a
clear demonstrable reason as to why the risk is too great. And I
fear that we are battling a culture which is the opposite and
starts from the perspective of needing to justify why you should do
something.

One of my general approaches in life is that I would far rather
people try something and it goes wrong and they learn from it than
that people don’t try in the first place.

There are many different levels of severity under the heading
learning difficulties. People with mild and moderate learning
difficulties were described to me as being the invisible
service-users because their difficulties are not as obvious. Is
there a danger in the White Paper that they are being sidelined a
little and could be at risk of losing their services by being
re-assessed and by the type of service changing? Are there going to
be enough services available for people whose needs are not as
severe as others?

I think we need to ensure that that doesn’t happen.
I’m very clear that things like employment and direct
payments apply to everybody no matter what the complexity of their
needs. It should open up a whole new range of possibilities for
people whose needs are less complex. So I think that even if people
with less severe learning disabilities are not necessarily the
reason why some initiatives take place, I think there will pretty
quickly be spin-off benefits for people.

The parents and carers of people with learning difficulties
will often be more vocal and more able to express their opinions.
How are you going to ensure that the advocacy is reaching the
person with the learning difficulty and it is their view that is
being expressed and followed?

I think we need to have a range of different approaches to
advocacy. We need to support the development of self-advocacy,
which is owned and controlled by people themselves, and that is
arguably the most powerful form of advocacy. We need to have
citizen advocacy, we need to have professional advocacy, and we
need to recognise the role of the family’s advocate. So there
are lots of different ones and we need to listen to all of them.
There will be tensions. But one of the things we need to do is find
ways of starting afresh in terms of relationships that often exist
between services and parents. One of my favourite phrases is
reality socially constructed. People behave in the way they do
because people’s experiences have told them to behave in that
way. Parents can be seen as being aggressive and awkward because
they have had bad experiences that have involved local authorities
or the NHS in the past. So they have learnt to get a bad deal and
they have learnt to behave accordingly. Because of that,
professionals in social services experience parents being difficult
and may behave in an antagonistic way towards the parents. And that
feeds the parents’ behaviour. So we’ve got to find a
way of cutting into that.

The White Paper looks at providing help and putting plans in
place for people with learning difficulties living with carers aged
over 70? Is that too old? Perhaps you ought to be looking at all
carers aged over 60, or perhaps even younger, and that a plan ought
to be in place from then?

That age was chosen in order to be realistic in terms of the
short-term planning in terms of the people who need to do that
work. I think it’s better to, at this stage, establish a
target which is deliverable and expect people to deliver on it
rather than one that is a bit more ambitious. I could envisage that
it will change over time. You have to start somewhere. I would hope
that partnership boards would agree to set themselves a different
target rather than waiting for government to change it because it
would seem good practice.

In the White Paper it suggests that everybody should have
person-centred planning…

It’s set certain priority targets for groups of people.
The eventual aspiration is that anybody who wants one should have
one.

There is a fear among some of the people I have spoken to
that this could become a bit like some of the other systems
introduced in the past that have become a series of tick boxes.
Particularly with people who have difficulty communicating, the
time that needs to be spent on one of these plans is considerable.
If these plans are for everybody, is there a danger that they will
be dumbed down?

The person-centred planning guidance tackles this head on.
It stresses two or three things. Firstly, that targets
should be about a gradual growth rather than setting over-ambitious
targets based on numbers. Secondly, it draws a distinction between
person-centred planning and person-centred approaches.
Person-centred planning is about people with learning disabilities,
with their friends and their families, working out want they want
in life. So it’s like a life vision. Then care management and
health professionals and care programme approach and all those
things then need to ensure that they develop person-centred
approach – in other words, work in a way that uses a starting
point that the person in their person-centred plan said they wanted
in life. So what you’ve got is a need to take lots of effort
to increase the number of people with person-centred plans that
they own and control themselves while at the same time changing the
way that care management operates and behaves so it no longer
starts from the perspective of what services have we got. It starts
with the perspective of this is what the person has said that they
wanted, how can I find a way of getting them what they want. So in
that sense we are not saying that everybody has to have a
person-centred plan. What we are saying is that care management
needs to have a person-centred approach towards everybody and we
need to gradually grow the number of individual person-centred
plans.

Is it not idealistic though, in a resource-limited sector,
to say that we are not going to start with the services we’ve
got, but with what services the person wants?

I guess that’s why we’re taking a gradualistic
approach. You can’t pursue that in the absence of looking at
strategic service development. You would have financial chaos if
one by one people were opting out of the day centre because they
wanted to do something else. So what you need to do is maybe
strategically say we are hearing people say that this day centre
doesn’t work for them so lets actually – using
person-centred planning – pose a question about do we need to
change the day centre. So you can actually merge together
individual plans and aspirations with strategic shifts.

What is the partnership board guidance intended to
cover?

The partnership guidance is different because it’s not
saying what partnership working is. It’s much more about
ideas, hints and tips about how to go about developing good
partnership working. What matters is actually building a
relationship between organisations as opposed to creating
structures. So you don’t start with your structures, you
start with how you can work together more effectively. The guidance
offers a framework for how people can self-audit and assess the
state of their partnership working, so that they can then, out of
that, develop an action plan to identify the areas of weakness.
There are also a series of short handy hints on partnership working
with different sectors, such as how to work effectively with
housing, what matters to them. It talks a bit about some of the way
boards might operate differently in order that they can involve
people effectively. But the ideas and tips about involving people
with learning disabilities is contained in the Deciding Together
guidance.

How are you physically going to make people change the way
they work given that the 1993 Mansell guidance was, to a large
extent, ignored?

How do you get people to do it differently? Firstly, force
people to publicly listen to, face, and have to respond to people
about what they are doing and why. That’s incredibly
powerful. Secondly, the implementation support team. What you have
got here is a team across the country there to help people. We have
a small budget at our disposal to do things and we will be
undertaking activities targeted in part at those priorities and
deliverables but also part of our focus will be around changing the
culture. So we will be doing stuff around leadership development
and change management. Thirdly, is the performance monitoring,
performance management stuff, if we can get that right. There was
none around the Mansell report, so in a sense people could ignore
it. There is going to be performance monitoring around Valuing
People. It will be more than the indicators. It will also be a more
qualitative process as well, to find out more about what’s
really going on. I see this as a relationship between people on the
ground, the development team, and the SSI and whatever NHS system
comes into play. Doing the performance management will be a
three-way relationship as opposed to something you just come in and
check periodically. It will be an on-going, long-term
relationship.

What are your thoughts on how the learning disability
partnership boards will fit in with the incoming Care
Trusts?

The government’s guidance on Care Trusts indicates that
there are likely to be organisational routes other than Care Trusts
for learning disabilities, and that’s because of the agenda
about jobs, education, housing and so on. That’s why the
local authority chief executive has been made responsible for the
partnership board. So I think the use of the Health Act
flexibilities is probably the place to start thinking about.
That’s not to say that some learning disability health
professional wouldn’t find themselves working in a
multi-faceted Care Trust.

You don’t think Care Trusts are the right route for
services for people with learning difficulties?

If they are proposing a learning disability-only Care Trust,
they need to give serious thought as to how a Care Trust structure
could deliver on the employment, housing, education and leisure
priorities in Valuing People which are as important as the health
and traditional social care elements. However, the NHS Plan White
Paper clearly said that if people are not working in partnership
then the secretary of state reserves the right to impose (a
partnership arrangement).

How about fitting with Local Strategic
Partnerships?

I think they are crucial. Given that the government is still
exploring what LSPs will be in practice, the context is that the
partnership board will in some way report in to the LSP. I see the
LSP as being a real opportunity to build those links with the
employment sector, with the local community in its widest
context.

What are your concerns in terms of the boards actually
operating and implementing the White Paper?

My major concern is that they will turn into an old-fashioned
planning group with a few more people present. In order for that
not to happen, they need to find quite new and radical ways of
operating, not working as a traditional meeting.

Can you give me an example?

Well, a couple of places are talking of the notion of the
partnership board as a conference or event. So four times a year
they have a great big workshop, and then people split off into
sub-workshops to talk about housing, so the housing person
doesn’t have to sit though two-and-a-half hours of discussion
that’s of no relevance to them. And that sort of format ought
to be easier for people with learning disabilities too.

And the second bit is organisations need to have the courage to
accept that they can’t operate unilaterally outside of the
partnership board arrangements. So, any changes to the care
management that develop because of person-centred planning, yes
they are the statutory responsibility of the local authority, but
they don’t agree those without taking them through and
getting them agreed by the partnership board.

And I think that if we can get those two things agreed –
news ways of working and recognising that you don’t act
unilaterally – then I think it will begin to make a
difference.

So the local authority really has to change its way of
thinking and recognise there is a new body that has to be involved
and consulted?

Yes. A body which it is a central part of. But it’s not
just local authorities. It’s a bigger challenge for the NHS
more than anybody else really. I think the cultural challenges to
the NHS are