Partnership working breakdown Buckinghamshire

The failings of a Buckingham residential home for people with learning disabilities serves as an example of what happens when partners don’t see eye to eye. Emma Parsons reports

Matthew Lewis is a 37-year-old man with severe learning disabilities. He cannot speak or look after himself he needs one-to-one attention for 95% of his waking life.

After 18 months in a new care home, during which his care needs were never properly assessed and his basic human rights were breached, he became so angry and depressed his parents had to care for him at home for three months, with no outside support.

Clear evidence of physical neglect at the care home included going unwashed and wearing dirty clothes on one occasion when his parents came to pick him up they found him soiled with urine and faeces and no explanation, apology or help with cleaning him up was offered.

Staff at the care home were frightened by a violent and sexually deviant resident and locked their doors at night, leaving other residents vulnerable. Matthew was once found bleeding from the rectum and the doctor could not rule out sexual abuse.

As these events unfolded his parents made repeated complaints but received no satisfactory answers. It culminated in Matthew’s breakdown when he refused to return to the care home after his Christmas break at home.

Buckinghamshire Council and Oxfordshire and Buckinghamshire Mental Health Partnership Trust were both found guilty of maladministration causing injustice in the first-ever joint investigation by the health and local government ombudsmen in March. They were ordered to pay £16,000 each in compensation.

The joint report was made because of the partnership arrangement between the two authorities in running the care home. Parts of the complaint, which should have been dealt with by one or other of the authorities, had become so intertwined the ombudsmen felt it was in the best interests of the complainants – Matthew’s parents – to have one point of contact.

Partnership arrangements

In their report the local government ombudsman and the parliamentary and health service ombudsman pointed to problems with the partnership arrangements.

Although Matthew – referred to under the pseudonym Frank Taylor in the report – was in the care of the trust, which was running the home when he was moved there, the council took over its management sometime shortly after he arrived. The two bodies could not even agree exactly when control of the home was handed over.

“The council has said that it assumed day-to-day managerial control only from 1 September 2002 although in the trust’s view the council took over both funding and managerial responsibility from July 2002,” says the report.

The matter of who ran the home for those three months illustrates the lack of communication and distinction of responsibility between the two bodies.

The report also found “agreement could not be reached about who should take responsibility for [Matthew]”.

“The delivery of a service through a section 31 agreement [the contract under which the council took over the running of the care home] poses interesting and difficult questions about public bodies working in partnership,” the report says.

At a time when partnerships between health and social services are being touted as the future, these questions are pertinent. The 2004 public health white paper Choosing Health: Making Healthy Choices Easier spells out the need for councils to work as partners with health providers.

In theory, partnerships are the answer, says Judy Wurr, an independent consultant in community care training, but their correct implementation is crucial. “Every report [into this] will show a lack of action in communication between departments and within departments,” she says.

In 1990 the watershed was the NHS and Community Care Act that set the theme for partnership working, but since then there will have been “tens, maybe hundreds” of cases like Matthew’s, she says.

“The legislative framework [for partnership delivery] and subsequent guidance is sound but its implementation is so variable and so localised because power is devolved down for people to implement their own processes. All the answers are there in the guidance, but it doesn’t say health and social services must work together.”

Constant policy change is a real challenge, as are institutional barriers and professional boundaries. She adds: People have a vested interest in maintaining the status quo. Most organisations, whether public or private, depend on staff who depend on that organisation for their job, money and lifestyle. They will resist change, it’s human nature.”

The lack of formal links between the agencies involved in the care of a person with complex health and social care needs is a problem.

“As well as the health and social welfare agencies there are other statutory organisations which should be looking out [for people with learning disabilities], such as the police and the Office of the Public Guardian, but they are not linked. They can liaise locally if people are proactive about it, but they need to be formally linked,” adds Wurr.

“I expressed real concerns about learning disability services in Cornwall in November 2000 but because the agency to which I reported had no statutory duty for health and social welfare, and no links to other agencies, I know that information went nowhere. It was 2006 before the poor practice in NHS reprovision was exposed.”

Local government ombudsman Tony Redmond, who reported on Matthew’s case, also thinks partnerships are a good idea but expects to be conducting more joint investigations into complaints as they become more common, and knows of three or four already in the pipeline. He says that with partnerships that go wrong it is often unclear where to turn: “[The lines of] accountability can be blurred.”

In Matthew’s case, he says, “there wasn’t absolute clarity about the respective roles in the section 31 agreement”.

Matthew’s mother Chris Lewis feels the authorities actually used this lack of clear accountability as an excuse for inaction, arguing that health and social services “colluded” in not giving answers. Strategic director for adult social care at Buckinghamshire Council Rita Lally admits “some of our staff were a bit confused over who should deal with things,” adding, “the fundamental issue about [Matthew’s] case is we should have known about the state of those services, but the fact is we didn’t. When we started to [find out] we were concerned about all the residents in the homes. We could have terminated the agreement and walked away but on balance we felt that wasn’t the right thing to do.”

Improvements

Buckinghamshire now has several joint posts across the health and local authorities. There are four joint commissioners with their teams and a joint director of public health. Things may be better there now lessons have been learned and the service has been reorganised. But for Matthew there is no change. He still does not have a home in which he is settled and secure.

“He’s more vulnerable now and gets flashbacks so it’s much more difficult to find the right care for him and we’re still looking,” says his mum. “We’re in the hands of the people who abused us and him. In any other walk of life the victim never would have to go back to their abuser and ask for help. Of course we don’t trust them.”

Trial partnerships are taking place all over the UK as local authorities and primary care trusts try to work out how to work together. Some are considering the appointment of a single chief executive to manage both authorities.

Whatever the arrangement, the lines of accountability must be clear. If people are to receive the service they have a right to expect, in-fighting and passing the buck must stop.

Multi-agency working and adult protection 

Adult care: Star ratings and the seven outcomes sees councils improve 

Jon Glasby and Helen Dickinson on interagency co-operation 

This article appeared in the 29 May issue under the headline “When the chain breaks…”